Responding to a Poliovirus Event Or Outbreak

STANDARD OPERATING PROCEDURES RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK

VERSION 3.1 MARCH 2020

STANDARD OPERATING PROCEDURES RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK

Version 3.1 March 2020 Published by the World Health Organisation (WHO) on behalf of the Global Polio Eradication Initiative (GPEI) Standard operating procedures: responding to a poliovirus event or outbreak, version 3.1 ISBN 978-92-4-000299-9 (electronic version) ISBN 978-92-4-000300-2 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Standard operating procedures: responding to a poliovirus event or outbreak, version 3.1. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Printed in Switzerland Design by Inis Communication – www.iniscommunication.com Contents

Acronyms and abbreviations iv Vaccine management and reporting 36 Routine immunization: Recovery and 1 Overview v strengthening 36 2 Strategic response framework 8 8 Surveillance following 3 Poliovirus events and outbreaks 9 investigation 37 Definitions 9 Surveillance enhancement 37 Classification of vaccine-derived polioviruses 9 Environmental surveillance 38 Event or outbreak 10 Strategies for special populations Defining “Day 0” for response monitoring 10 and security-compromised areas 39

4 Detection, notification and 9 Communication and social investigation 13 mobilization 40 Detection 13 Strategic C4D framework for polio outbreak response 40 Notification 13 Data gathering to guide C4D activities 41 Investigation 13 Communication strategies 41 Reaching special populations and 5 Risk assessment 18 conflict-affected areas 42 Initial risk assessment 18 Type 2 poliovirus 18 10 GPEI support 43 Including sentinel events in the risk Coordination 44 assessment 19 Budgets and financing 44 Ongoing risk assessment 19 Human resource surge 44 GPEI performance standards 45 6 Response standards – overview 20

Minimum response standards for 11 Monitoring and evaluation of poliovirus events and outbreaks 20 response 46 Outbreak grading 22 Monitoring quality of SIAs 47 Standard timelines for outbreak response 23 Monitoring surveillance enhancement 48 7 Vaccination response 24 Outbreak response assessments (OBRAs) 48 Is the outbreak over? 49 Timing and scale of immunization activities 24 International Health Regulations 50 High-quality campaigns 33 Documenting lessons learned 51 Planning for mobile, hard-to-reach and special populations 34 Concurrent circulation of different Bibliography 52 poliovirus types 34 Annexes 54 Integration with other health interventions 34 Annex 1.Risk assessment overview: Summary of Inactivated polio vaccine (IPV) 35 elements for systematic risk assessment Requesting vaccine 35 of a new VDPV, WPV or SL2 isolation. 54 Annex 2. Timeline and responsibility for outbreak response activities from Day 0 to outbreak closure 54 Acronyms and abbreviations

AFP acute flaccid paralysis C4D Communication for Development EOC emergency operations centre EOMG Eradication and Outbreak Management Group ES environmental surveillance fIPV fractional dose inactivated polio vaccine GIS geographic information system GPEI Global Polio Eradication Initiative GPLN Global Polio Laboratory Network IDSR Integrated Disease Surveillance and Response IHR International Health Regulations (2005) IM independent monitoring IPV inactivated polio vaccine LQAS lot quality assurance sampling NGO nongovernmental organization NPAFP non-polio acute flaccid paralysis NPENT non-polio enterovirus OBRA outbreak response assessment OPRTT Outbreak Preparedness and Response Task Team OPV oral polio-containing vaccine bOPV bivalent OPV (contains Sabin types 1 and 3) tOPV trivalent OPV (contains Sabin types 1, 2 and 3) mOPV2 mOPV2 monovalent OPV (contains Sabin type 2) RED Reaching Every District RI routine immunization RR rapid response SAGE Strategic Advisory Group of Experts on Immunization SIA supplementary immunization activities SIAD short interval additional dose SOPs standard operating procedures SR surge response STOP Stop Transmission of Polio UNDSS United Nations Department of Safety and Security UNICEF United Nations Children’s Fund VDPV vaccine-derived polio virus aVDPV ambiguous vaccine-derived polio virus cVDPV circulating vaccine-derived polio virus iVDPV immunodeficiency related vaccine-derived polio virus WHE WHO Health Emergencies WHO World Health Organization WPV wild poliovirus WPV1 type 1 wild poliovirus WPV2 type 2 wild poliovirus WPV3 type 3 wild poliovirus

iv RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK 1 Overview

Background to a non-endemic country, or when VDPV events and/or outbreaks of any type (VDPV1, VDPV2 or As of July 2018, three countries remain endemic for VDPV3) are detected in any context, whether a new type 1 wild poliovirus (WPV1): Afghanistan, Nigeria emergence or previously undetected circulating and Pakistan. In 2015, type 2 WPV (WPV2) was vaccine-derived poliovirus (cVDPV). declared eradicated, and type 3 WPV (WPV3) was last reported in November 2012. In 2016, type 2 The SOPs summarize the roles and responsibilities oral polio-containing vaccine was withdrawn from of countries and GPEI partners during a polio all routine immunization programmes worldwide, outbreak or event. Since WPV2 is now considered replacing trivalent oral polio vaccine (tOPV) an eradicated pathogen, specific measures are containing attenuated poliovirus vaccine serotypes outlined for responding to type 2 events and 1, 2 and 3 with bivalent oral polio vaccine (bOPV) outbreaks, including how to request and account containing only types 1 and 3. for monovalent oral type 2 polio vaccine (mOPV2) from the global emergency vaccine stockpile. While efforts to eradicate WPV1 continue in endemic countries, the world needs to be prepared for the Guidance in these SOPs relies on scientific evidence international spread of WPV, and for vaccine-derived and expert consensus, while remaining grounded in poliovirus (VDPV) of serotypes 1, 2 or 3, which operational realities and the context of waning global can also still emerge in different contexts. Poliovirus immunity to type 2 poliovirus. Critical aspects of the events or outbreaks may arise due to a number of SOPs result from broad consultation of expert advisory possible factors, including low population immunity, groups, including the World Health Organization importation of virus, or a containment breach from (WHO) Strategic Advisory Group of Experts (SAGE) laboratory or vaccine manufacturing facilities. on immunization, and endorsement by the GPEI Eradication and Outbreak Management Group. Purpose These SOPs do not cover: WPV1 case response due to The purpose of these standard operating procedures local transmission in an endemic context, field-level (SOPs) is to offer policy guidance and to provide operational guidance or tools for planning high- performance standards on how to respond to any quality supplemental immunization activities (SIAs), type of poliovirus outbreak or event in a timely or detailed methods for enhanced surveillance. and effective manner, and specifically, to stop an outbreak within 120 days. What’s new in this version

This guide is for national governments and public This document updates the most recent version of health decision-makers who coordinate responses to the Standard Operating Procedures: Responding poliovirus events and outbreaks, and their global, to a poliovirus event or outbreak", Version 3, regional and country-level partners. published January 2019. Version 3.1 incorporates lessons learned from outbreak response efforts and Scope takes into account the current context of the global program. These Global Polio Eradication Initiative (GPEI) SOPs establish response standards and timelines Revisions are highlighted throughout the document for actions to stop transmission when WPV spreads and summarized below.

RESPONDING TO A POLIOVIRUS v EVENT OR OUTBREAK 1. Revisions to Type 2 Vaccination Response as more mOPV2 is used in response to new and Scope ongoing outbreaks while mucosal immunity to While the number of cVDPV2 outbreaks due to pre- Type-2 poliovirus continues to decline. switch use of tOPV has declined as expected, the Outbreaks of cVDPV2 will still require use of mOPV2, number of new emergences sharply increased starting which remains the only tool capable of stopping the in the second half of 2018, and in 2019 is now far outbreaks in areas with poor sanitation. However, use higher than anticipated at the time of cessation. New of mOPV2 will continue to risk the generation of new emergences have been concentrated around areas of outbreaks, until an alternative vaccine which does recent mOPV2 use in sub-Saharan Africa, but recent not generate new outbreaks becomes available. In the outbreaks confirmed in other regions of the world interim, a revised response strategy for detections of (e.g. Western Pacific and Eastern Mediterranean) VDPV2 will be needed, balancing the increased risk demonstrate additional risk elsewhere. of cVDPV2 spread and increased risk of mOPV2 use. Continuation of outbreaks requires improvements in Since the number of VDPV1 and VDPV3 outbreaks the timeliness and quality of outbreak response so continues to be minimal and there is less risk that any ongoing transmission in mOPV2 response associated with bOPV vaccine used in SIA response, zones is stopped. Additionally, the sharp increase the recommendations for these outbreaks should in cVDPV2 outbreaks is possibly as a result of proceed as outlined in version 3. population movement of recently vaccinated children into areas with low population immunity or errant Details of the revisions are provided within use of mOPV2 outside of response zones. This trend the relevant text of the “Chapter 7 Vaccination for response to VDPV2 only is likely to intensify in the coming year, Response”. However, , the key proposed changes are summarized below:

Version 3 Version 3.1 Comment Conduct rapid Conduct rapid (<14 days) focused Initial response (R0) should be rapid, (<14 days) focused response of 100–400k children for R0 focused, and small scale; the intent should response of 200– be to maximize quality in high-risk areas 500k children for near the detection. If it cannot be conducted SIA Round 0 quickly (within three weeks), the country team may consider proceeding directly with SIA1 and its appropriate target population as per below. This decision should be made in consultation of GPEI partners. Response scope Response scope for newly infected areas Potentially increase response size for R1 and for cVDPV2 should with cVDPV2 should be R0 (100 – 400k), R2 (ideally when quality can be supported be 1–2 million* R1, R2 (1-4 million* children) and mop up by adequate technical assistance) in order children for R1 to improve the chance of rapidly stopping and R2 For additional cVDPV2 detections transmission. (regardless whether related to an already established or new) in areas where >– Breakthrough transmission in prior 2 mOPV2 SIAs beyond R0 have been response zones may indicate low quality in conducted within the last 6 months, the initial SIAs and signify a requirement for conduct at least 2 additional SIAs but further technical assistance. Additional SIAs reduce scope to <2 million. in these areas are reduced in size to allow quality improvements in known transmission For additional cVDPV2 detections areas and to reduce the potential for further (regardless whether related to an already vaccine-derived poliovirus emergence. established or new) in areas where ≥ 2 mOPV2 SIAs beyond R0 have been conducted more than 6 months ago, response scope should be R0 (100 – 400k), R1, R2 (1-4 million* children) and mop up

6 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Version 3 Version 3.1 Comment Detection of aVDPV2 Detection of a newly emergent single Version 3.1 shifts the default for aVDPV2 (single isolation) VDPV2 (e.g. aVDPV) in an area with mOPV2 detection to trigger a SIA response since does NOT require use within the last 12 months does NOT the vast majority of aVDPV2s found in sub- an immediate require an immediate vaccination response Saharan areas without recent mOPV2 use vaccination unless deemed to be found in a high-risk in end-2018 and 2019 have proceeded to response unless scenario due to virology, context, or become cVDPV2s. Local circumstances may deemed to be potential international spread^ require exceptions that should be discussed found in a high- with GPEI partners. risk scenario (See Detection of a newly emergent single chapter 5, Risk VDPV2 (e.g. aVDPV) in an area without Assessment). mOPV2 use within the last 12 months requires an immediate vaccination response of 100-400k children unless the Detection of aVDPVs in areas without prior epidemiology and program situation are mOP2 use in the last 12 months should deemed to require further assessment. trigger the same number of SIAs (e.g. R0 + R1 + R2) as for a cVDPV2 but initially on Response scope for additional R1 and R2 a reduced scale. Maintain highly targeted for these detections may be reduced to response around the aVDPV detection 100–400k; however, additional SIAs with unless additional surveillance/assessment increased scope should be conducted determines ongoing community transmission if evidence of further transmission (i.e. in the same area which would signify the confirmed cVDPV2) is obtained. possible necessity to expand the scope.

*All response sizes are general recommendations and should be based on local epidemiology and other risk factors determined through a local assessment and in consultation with GPEI partners. ^See SOP, V3, Table 3 for details. NOTE: The proposed total number of responses SIAs has not changed. Two campaigns must still be completed after the last detected virus. A high-quality mop-up round may be considered as one of these campaigns, if the area of the detected virus was covered twice.

Other revisions include: 5. The scope and timing of Outbreak Response Assessments (OBRAs) have been revised to reflect 2. Correction on the IHR notification process changes in the program and after feedback from (Chapter 4) and additional information on IHR WHO and UNICEF regional and country teams criteria to assess countries as no longer being infected (Chapter 11). by WPV or cVDPV2 (Chapter 11) 3. Clarification on AFP contact sampling and Supporting documents Targeted healthy children stool sampling including Resources referenced in these SOPs are available how and under what circumstances they should be on the GPEI website (http://polioeradication.org/ conducted (Chapter 4). tools-and-library/resources-for-polio-eradicators/gpei- 4. Due to improvement of global vaccine supply, tools-protocols-and-guidelines/) and/or are listed in recommendations for IPV use in an outbreak the bibliography. setting and the process for requesting IPV has been updated (Chapter 7).

RESPONDING TO A POLIOVIRUS 7 EVENT OR OUTBREAK Strategic response 2 framework

This framework guides national responses to All countries must plan for the eventuality of poliovirus events or outbreaks, providing the basis a poliovirus importation or local detection, for coordination and collaboration among partners, particularly those with low immunization coverage to ensure that national polio response activities are and those at risk of importation, or those with fully supported. facilities that handle the poliovirus (e.g. laboratory, research, vaccine manufacturing facilities). A Below are the essential elements to a successful preparedness plan should be developed and tested response to a polio event or outbreak: in a polio outbreak simulation exercise to ensure that public health personnel and emergency systems i) Fully engaged national and subnational are prepared to react quickly and effectively if any governments poliovirus isolate is detected. Countries with high- ii) Rapid detection, notification, investigation and risk populations and/or facing conflict, insecurity risk assessment or access challenges must consider how to prioritize iii) Strong advocacy, communication and social these populations and areas, adapting strategies to mobilization the local context. iv) A robust immunization response, where indicated v) High-quality and enhanced surveillance.

8 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Poliovirus events 3 and outbreaks

Definitions VDPVs are identified based on their degree of genetic divergence from the parent OPV virus strain. Poliovirus isolates detected in persons or in the Viruses that are >1% divergent (i.e. ≥ 10 nucleotide environment can fall into three major categories: changes, for types 1 and 3) or >0.6% divergent wild, Sabin and Sabin-like, or vaccine-derived. New (i.e. ≥ 6 nucleotide changes, for type 2) from the detection of a poliovirus isolate may constitute an corresponding OPV virus strain, are labelled as emergency, which can be categorized as an event VDPV.b or an outbreak, depending on characteristics of the isolate and the context in which it appears (see below). Classification of vaccine-derived 1. Wild polioviruses. At this stage of the polioviruses eradication programme, each case or isolate VDPVs are classified into three categories: of wild poliovirus requires rigorous review as it may represent an importation, a local i) Circulating vaccine-derived poliovirus containment breach, or ongoing transmission (cVDPV) is a VDPV demonstrating person-to- in endemic countries. person transmission in the community, based 2. Sabin virus. Sabin virus is the live attenuated on evidence from human and/or environmental poliovirus in oral polio vaccine (OPV). This detections of related viruses. category also includes Sabin-like polioviruses, ii) Immunodeficiency-related vaccine-derived which are those genetically very closely related poliovirus (iVDPV) is a VDPV isolated to the strains in OPV but that have not yet from an individual with evidence of primary diverged sufficiently to meet the definition immunodeficiency. Unlike immunocompetent of a vaccine-derived virus (see below). Sabin persons, who excrete the vaccine virus for a and Sabin-like viruses are commonly detected limited period, in rare cases immunodeficient following vaccination with OPV.a persons may excrete a genetically diverged vaccine virus for an extended period of time 3. Vaccine-derived polioviruses (VDPVs). In after receiving OPV. under-immunized populations, if Sabin-like viruses continue to be transmitted from iii) Ambiguous vaccine-derived poliovirus person-to-person they can continue to diverge (aVDPV) is a classification of exclusion when genetically and eventually in rare instances the investigation does not support classification become VDPVs, which may evolve and can as cVDPV or iVDPV. Isolates may be from eventually regain the ability to cause paralysis. persons with no known immunodeficiency or from an environmental sample, without evidence of circulation.

a Type 2 Sabin and Sabin-like virus should no longer be detected except where mOPV2 has recently been used for response. Any Sabin or Sabin-like type 2 virus outside this circumstance warrants urgent investigation. b See “Classification and reporting of vaccine-derived polioviruses (VDPV)”. Geneva: Global Polio Eradication Initiative; 2016 http://polioeradication.org/( wp-content/uploads/2016/09/Reporting-and-Classification-of-VDPVs_Aug2016_EN.pdf, accessed 8 November 2018).

RESPONDING TO A POLIOVIRUS 9 EVENT OR OUTBREAK These definitions are relevant to isolates of all Defining “Day 0” for response poliovirus serotypes (i.e. 1, 2 or 3). monitoring The GPEI guidelines, Classification and reporting of All poliovirus events and outbreaks will trigger the vaccine-derived polioviruses,c provide definitions and same set of response actions including; investigation, describes the laboratory and field epidemiological risk assessment, surveillance enhancement, strategic investigation needed to classify an isolate. advocacy, and communication, with or without a Occasionally, investigation and genetic sequencing of vaccination response. a VDPV may take some time. A new isolate unrelated to any known VDPV is referred to as a VDPV “pending For the purpose of performance monitoring, a “Day 0” classification” and may require response measures. A is defined so that progress of all response actions can previously classified virus may also be re-classified be monitored against the standards set in these SOPs. based on new information. Day 0 is the day of receipt of the genetic sequencing laboratory result by WHO headquarters. Event or outbreak Previously isolated VDPVs, classified as ambiguous Table 1 categorizes new or continuing poliovirus or pending classification, may be reclassified as isolation as an event or outbreak to help describe circulating (i.e. an outbreak) if another related the extent of person-to-person transmission and poliovirus is detected indicating evidence determine an appropriate response. The term of transmission. “outbreak” is reserved for situations with clear evidence of person-to-person transmission. For outbreaks or medium to high-risk events (deemed to require a vaccination response), Day 0 remains Events may evolve into outbreaks. the same for the purpose of operational response monitoring, even if new information confirming transmission becomes available.

In the case of a low-risk event without vaccination response, genetic sequencing information for new isolates may subsequently confirm transmission. In this case, consideration may be given by GPEI to adjust Day 0 to the date the new sequencing information is received.

c See “Classification and reporting of vaccine-derived polioviruses (VDPV)”. Geneva: Global Polio Eradication Initiative; 2016 (http://polioeradication.org/ wp-content/uploads/2016/09/Reporting-and-Classification-of-VDPVs_Aug2016_EN.pdf, accessed 8 November 2018).

10 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Table 1: Definition of poliovirus events and outbreaks

Typology Definition Event Human (no Detection of: evidence of transmission) • VDPV in: - single acute flaccid paralysis (AFP) case or asymptomatic person (e.g. contact), or - one or more persons,1 with no evidence of further community-level circulation (iVDPV or aVDPV isolates) OR • Type 2 Sabin or Sabin-like isolate from individual sample(s) more than four months after use of any type 2 containing OPV (i.e. mOPV2 or tOPV) OR • WPV1, WPV2 or WPV3 infected individual with suspected or documented type-specific virus exposure in a laboratory or vaccine production facility. Environmental Detection of: • WPV single environmental sample without follow-up evidence of virus excretion;2 OR • VDPV without evidence of further transmission, such as: - a single environmental sample without evidence of prolonged circulation; or - an aVDPV. OR • Type 2 Sabin or Sabin-like isolate from environmental sample(s) more than four months after use of any type 2 containing OPV (i.e. mOPV2 or tOPV).

Outbreak Human (evidence of Detection of: transmission) • any WPV-infected individual(s)1 (i.e. outside endemic areas and without documented exposure to WPV in a laboratory or vaccine production facility); OR • any cVDPV infected individual(s).1 Environmental Detection of: • two or more separate3 environmental samples positive for WPV with genetic sequencing information indicating sustained local transmission; OR • a single environmental sample positive for WPV with follow-up evidence of virus excretion2 (and no documented exposure in a laboratory or vaccine production facility); OR • any cVDPV positive environmental sample(s).

1 Infected person can be an AFP case, or an asymptomatic/healthy person. 2 Evidence of virus excretion as identified during follow-up community investigation. 3 Separate means that samples were collected at more than one distinct environmental surveillance collection site (i.e. no overlapping of catchment areas), OR samples were collected from one site, but collection was more than two months apart.

RESPONDING TO A POLIOVIRUS 11 EVENT OR OUTBREAK END OF OUTBREAK notiﬁ cation notiﬁ Time from lab result lab result Time from WPV human cVDPV human WPV environment cVDPV environment OUTBREAK WPV with genetic sequencing that suggests local local WPV with genetic sequencing that suggests transmission of virus excretion evidence follow-up • for positive samples environmental ≥2 separate • WPV with for positive sample environmental 1 single

OUTBREAK OR HIGH-RISK EVENT WPV human iVDPV aVDPV aVDPV vaccine production facility) production vaccine WPV environment With possible or documented wild or documented With possible poliovirus exposure (laboratory or (laboratory exposure poliovirus EVENT WPV VDPV VDPV human Type 2 Type human or Sabin like Sabin like environment environment Poliovirus type 1, 3 or 2 DAY 0: DAY cation notiﬁ Lab result Figure 1: SOPs at a glance: Events and Outbreaks Events at a glance: 1: SOPs Figure

12 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Detection, notification 4 and investigation

Detection Investigation Samples collected from human (biological) or The country must investigate any poliovirus isolate environment sources during routine surveillance notifiable under IHR, whether the isolate is from AFP or an event or outbreak investigation are sent to a cases, AFP contacts or environmental surveillance. laboratory of the Global Polio Laboratory Network The GPEI will support the country as needed. (GPLN) to determine the presence of poliovirus. The virus can be identified through culture, intra-typic Local health authorities should initiate the differentiation and genetic sequencing. investigation within 24 hours of a poliovirus isolate report. The most effective approach is a joint epidemiological and social investigation with Notification support from the national level of any case and As soon as poliovirus is identified, the GPLN will affected community, as well as the gathering of inform the health authorities of the affected country relevant national data. Whether a known poliovirus and WHO at the country, regional and headquarters strain is isolated in a previously infected area or a levels. Under the International Health Regulations previously uninfected area, or a new poliovirus (2005) (IHR),d all notifiable polioviruses (see Box strain is detected, all require a comprehensive 1) must also be immediately reported by national detailed investigation. authorities to the IHR focal point at the respective Information from the GPLN and the epidemiological WHO regional office. and social investigation are used to describe the WHO headquarters will inform GPEI partners characteristics of the virus and determine if there when this information is received and validated. is evidence of person-to-person transmission. This Additional details, including any links to other will inform the risk assessment and classification. polioviruses, will be shared by the GPLN and WHO As investigation and classification can take headquarters as soon as available. days or weeks; it is critical to appreciate that response activities are often required before final Notification to WHO may lead to publication of a virus classification. disease outbreak news report on the WHO website, as appropriate, based on virus type, risk assessment and outbreak status.

d See “International Health Regulations” (2005), 2nd Edition. Geneva: World Health Organization; 2008 (http://www.who.int/ihr/ publications/9789241596664/en, accessed 8 November 2018).

RESPONDING TO A POLIOVIRUS 13 EVENT OR OUTBREAK Box 1. International Health Regulations 2005 (IHR) and the obligation to notify Under IHR, notification is required for all events that may constitute apublic health emergency of international concern. For polio this includes detection in human or non-human sources of: • WPV, • VDPV (type 1, 2, or 3), • and Sabin / Sabin-like type 2 viruses. Sabin / Sabin-like viruses types 1 and 3 are not notifiable. The national IHR focal point must notify WHO within 24 hours the IHR contact person at the respective WHO regional office of all notifiable polioviruses, without waiting for final classification.

Table 2 outlines the scope and objectives of an investigation.

Table 2: Investigation of poliovirus isolates from AFP cases, contacts or environmental surveillance

Investigation components Objectives Part A: 1. Detailed case investigation for a poliovirus • Gather information to confirm the event/ Investigating isolate from an AFP case or a positive contact outbreak the case or 2. Investigating the site of an isolate from • Identify possible source of infection/ environmental environmental surveillance causes of the event/outbreak isolate and 3. Describing the community context of any • Determine the number and characteristics local context detected isolate, regardless of source: of cases, the context for environmental • Population immunity isolates • Recent SIA performance • Population characteristics, movement and migration routes • Community social mapping. Part B: 4. Community search for additional cases of • Determine the geographic extent and Determining AFP and evidence of virus transmission: assess the risk of further transmission the • Surveillance Data geographic • AFP contact sampling extent of • Targeted healthy children stool sampling transmission • Community household search • Local Health facility search • Other community outreach

Part A: Investigating the case or history of treatment, injections and vaccination (including all routine and SIA doses of any polio environmental isolate and local vaccine, date of last vaccination, and reasons for context any missed doses). Clinical and family history should include any signs or symptoms of primary 1. Detailed case investigation of an isolate immunodeficiency, and a test for quantitative from an AFP case or contact immunoglobulins where indicated. For any poliovirus isolated from a child or adult An urgent epidemiological (i.e. person, place and (AFP case or contact), conduct a detailed clinical time) and social investigation of the AFP case and and neurological examination. Collect a detailed

14 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK close contacts is required. It is important to collect 3. Describing the community context of any detailed information on travel history, socioeconomic detected isolate, regardless of source and community context, distance to health facility The information outlined below should be collected or other barriers to vaccination, and other relevant following detection of poliovirus in a previously information. The GPEI form, Detailed epidemiologic uninfected community. For any subsequent detection case investigation form,e provides a guiding template f in the same area, focus on significant updates to the for a joint epidemiological and social investigation. general information previously collected.

2. Investigating the site of an isolate from Population immunity. Develop an immunity profile environmental surveillance based on available information such as type-specific vaccination status of non-polio AFP cases, routine Describe the catchment area of the infected sampling and SIA vaccination coverage data, and community site and other collection sites in the area, including immunization surveys. Determine the characteristics information on population demographics (especially of unvaccinated and partially vaccinated children, high-risk groups), population movement, and high-risk or special populations, and seek details of relevant institutions (e.g. health facilities, schools health-seeking behaviour. and bus parks or other transportation centres). For type 2 isolates, distinguish carefully between Describe the sewage or drainage system into the immunity to type 2 compared to types 1 and 3 collection site, complemented by geographic polioviruses, and pay special attention to birth information system (GIS) imagery where possible cohorts born since the switch or since last use of (e.g. elevation profile, links with other sites, and mOPV2. Estimate the population naive to oral density of dwellings). Document the history of the polio vaccine or protected only by inactivated polio site, collection schedule, timeliness and completeness vaccine (IPV) for type 2 poliovirus. of collection, and proportion of samples positive for non-polio enteroviruses (NPENT). Record any Collect epidemiologic evidence of any past poliovirus detected, including Sabin virus. poliovirus detections (WPV or VDPV) in the affected or surrounding communities. Review documented For Sabin 2 virus isolation, investigate immediately communicable disease incidence and transmission using the field guide and investigation template patterns, including vaccine-preventable diseases, available (unless within four months of a mOPV2 while paying special attention to diseases with response in the immediate area). faecal–oral transmission such as cholera and acute Investigation of a WPV isolate in a non-endemic bloody diarrhoea. country must consider possible release from g Recent SIA performance. Use immunization a laboratory or other facility, or importation coverage, independent monitoring (IM), and lot (e.g. byan incoming traveller), particularly when quality assurance sampling (LQAS) indicators from genetic sequencing to ascertain origin is still pending. recent SIAs to define the following: i) number and characteristics of missed children; ii) reasons for missing them; and iii) any interventions that worked to successfully reach missed children.

e See “Detailed epidemiologic case investigation form”. GPEI guidance. Geneva: Global Polio Eradication Initiative; 2011 (see document within GPEI library http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/gpei-tools-protocols-and-guidelines/, accessed 8 November 2018). f Country-specific tools required to investigate a poliovirus detection should be developed during outbreak preparedness and response planning. A national team to conduct the investigation should be trained as core capacity development for implementation of IHR or Integrated Disease Surveillance and Response (IDSR). g See “Public Health Management of Facility-Related Exposure to Live Polioviruses: Interim guidance in managing exposed persons for countries hosting facilities that maintain live polioviruses” on GPEI website library, http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/ gpei-tools-protocols-and-guidelines/).

RESPONDING TO A POLIOVIRUS 15 EVENT OR OUTBREAK For any type 2 poliovirus, in addition to information children 6–59 months, for the last three to five on any post-switch detection of Sabin 2 or previous years. Also consider evidence of implementation VDPV2, collect additional details regarding last of recommendations for surveillance strengthening known use of tOPV or mOPV2, quality of mOPV2 from recent programme or surveillance reviews. vaccine management, and steps taken to search for any remaining tOPV or mOPV2 vials. Further investigation in the community and health facilities are time and resource intensive, and Population characteristics, movement and so require close coordination with the relevant migration routes. Obtain a general overview of surveillance and laboratory colleagues to prepare for the affected population, including information on any surge requirements. Unless otherwise indicated, population density, social structure and networks, the strategies below should only be implemented presence of minority or non-local residents, and as part of the field investigation following detection community awareness of polio and immunization. of a new unclassified VDPV case or newly positive Highlight any security and access constraints. environmental sample (VDPV or WPV) in an area Take note of major population movements due to that has not had documented transmission within economic, seasonal or nomadic migration, religious the past 12 months. pilgrimage, insecurity, or natural disaster. Possibly relevant investigation strategies include: Community social mapping. Use formal or informal sources to gain an appreciation of AFP Contact sampling (also known as direct immunization practice and vaccine acceptance in contact sampling and close contact sampling) the community. Gather general information on should be conducted during the initial, or media reach, community influencers, and relevant follow-up AFP investigation, when an AFP case social groups. has inadequate stool specimens for laboratory confirmation of poliovirus. Part B: Determining the geographic It is the collection and laboratory testing of one extent of transmission stool specimen from three children in contact with an AFP case to support diagnosis of 4. Community search for additional cases of poliovirus in the AFP case. Children in contact AFP and evidence of virus transmission with AFP cases (referred to as AFP contacts) have a higher likelihood of asymptomatic infection Once a poliovirus has been detected from any and virus excretion. If poliovirus is isolated in a source, additional steps are required to ascertain stool sample from an AFP contact, this will also the geographic extent of possible transmission. confirm poliovirus in the AFP case. These activities can include a review of surveillance data, investigation of AFP contacts, others in the AFP contact sampling should not be community, and health facilities using strategies conducted for laboratory-confirmed cases that are often part of routine poliovirus surveillance, of poliovirus. but also useful in specific circumstances after a poliovirus has been confirmed (see also Section 8 Children (preferably <5 years of age) in contact on enhanced routine surveillance). with the AFP case in the week prior and/or two weeks after paralysis onset should be targeted Surveillance data. Conduct an in-depth review for specimen collection. The objective is to for polio across the country to analyze risk and identify children who had contact with the AFP determine the quality and sensitivity of the current case (e.g., touching, sharing toys, and sharing surveillance system. Include a review of AFP food) which may have resulted in infection with indicators at lowest applicable administrative level, poliovirus, if poliovirus is the cause of paralysis. including AFP detection, stool adequacy, and the Examples include siblings and other children non-polio AFP (NPAFP) immunization profile for living in the same household, and neighboring

16 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK children who played with the AFP case during had contact with the AFP case, should be the period of interest. These contacts are referred targeted for specimen collection. The objective to as close contacts. is to identify children that reside in the same community but are not close contacts. Under specific circumstances during a poliovirus outbreak, AFP contact sampling may be Any decision to do a targeted health children expanded for all AFP cases for a limited time stool sampling should be made at the national- period. Examples include AFP cases outside the level in consultation with laboratory colleagues. outbreak zone to detect further transmission, or AFP cases within a security compromised See AFP contact sampling job aidh and GPEI or hard-to-reach area to take advantage of the website for more information on the process for limited opportunities to reach this community. sampling and specimen labeling. Decisions on expansion should be made at the national-level with laboratory colleagues. Community household search. For any area with a newly detected VDPV or environmental surveillance See AFP contact sampling job aid and GPEI (ES) sample, a house-to-house search to identify any website for more information on the process for person with sudden onset of weakness or paralysis sampling and specimen labeling. in one or more limbs in the past 60 days can help Targeted healthy children stool sampling to determine if there is any additional community (also known as community contact sampling, transmission. The number of households to visit will community stool sampling, or asymptomatic depend on local population density and other risk children stool sampling) may be conducted factors. National authorities and/or GPEI technical following a new VDPV isolation when expert advisory bodies can provide further guidance. community transmission has not been Local health facility search. Conduct retrospective confirmed. The decision to conduct targeted case searches in health facilities (formal and healthy children stool sampling must be made informal) and document findings. Include at least in close coordination with national surveillance six-month record reviews for undetected/unreported and laboratory teams. AFP cases; and investigate unreported AFP cases. It is the collection and laboratory testing of one Assess clinicians’ knowledge of AFP surveillance and stool specimen from 20 asymptomatic children polio immunization performance and capabilities (i.e. children without AFP) to determine and provide sensitization as necessary. Complete a presence of poliovirus and hence, transmission search for vials of tOPV or mOPV2 where relevant. in the community. Other community outreach. As part of the search If there is already evidence of community- for any cases of AFP, including during household wide transmission, targeted healthy children search, investigators should engage local leaders and stool samplings should not be conducted. influencers in the community and sensitize them to the case definition of AFP and the importance of Children (<5 years old but preferably <2 years early reporting of AFP old) with no evidence of AFP, and have not

h See "Use of AFP contact sampling and targeted healthy children stool sampling: GPEI Job Aid. Geneva: Global Polio Eradication Initiative 2019. (see document with GPEI library http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/gpei-tools-protocols-and-guidelines/)

RESPONDING TO A POLIOVIRUS 17 EVENT OR OUTBREAK 5 Risk assessment

Initial risk assessment A detailed summary of elements to help countries prepare a robust risk assessment is provided, along Isolation of a poliovirus in a previously non-infected with additional resources and tools (see Annex 1: area represents an event or outbreak that requires Risk assessment overview for detailed guidance). national authorities to complete an immediate risk assessment to inform the type and scale of response. The purpose of the risk assessment is to Type 2 poliovirus review virologic and epidemiologic characteristics All type 2 virus isolations require special attention of the newly detected virus, event or outbreak when conducting a risk assessment and determining and determine the level of risk for further local or the type and scale of response. Following the global international spread as high, medium or low. withdrawal of type 2 containing OPV from routine The risk assessment is presented by national immunization programmes in April and May of authorities and/or WHO national or regional offices 2016, there is increasing risk of very rapid virus to GPEI partners within 72 hours of receipt of a spread associated with declining mucosal immunity genetic sequencing result, or outbreak confirmation. in children. The assessment reviews critical factors that will For type 2 poliovirus (VDPV2 or WPV2) detection, influence the type and scale of response and allows consultation with GPEI partners is systematic and GPEI to recommend appropriate action. will often result in a discussion with the mOPV2 A risk assessment addresses three risk elements: Advisory Group to review the risk assessment and virologic, contextual, and risk of international assess the need for a potential vaccination response transmission (see Table 3). with monovalent type 2 oral polio vaccine (mOPV2).

Table 3: Elements to assess risk for further poliovirus transmission that will influence type and scale of response

Risk element Sample of risk factors considered (not exhaustive) Virologic risk1 High degree of genetic deviation from parent Sabin, number and nature of nucleotide changes, and expert interpretation by virologists, etc. Contextual risk Recent poliovirus detection or other sentinel events, sensitivity of AFP surveillance system, high population density, low immunization coverage and population immunity, geographic access, conflict, inaccessible or hard-to-reach populations, and population movements, etc. Risk of international Border area with high population mobility, nomadic or refugee populations, cross- transmission border conflict, and international travel routes, etc.

1 Virologic risk is considered high for any WPV or cVDPV.

18 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK A detection of type 2 Sabin or Sabin-like virus in Ongoing risk assessment an area where mOPV2 has not been used in the previous four months is notifiable under IHR. Such Following initial investigation and risk assessment, a finding may reflect ongoing and/or unauthorized national authorities must continue to collect use of tOPV or mOPV2, as children vaccinated with detailed information to update the situation analysis OPV continue to shed Sabin virus for approximately and risk assessment (i.e. results from laboratory three months. For this reason, detection of type investigations, or detailed information on affected 2 Sabin or Sabin-like virus from any source four communities, etc.). Neighbouring countries/regions months or more after last mOPV2 use requires an must also continue to update their risk assessment investigation, risk assessment and IHR notification with support from WHO regional offices. to WHO. Relevant risk factors to include in the ongoing risk assessment include: Including sentinel events in the risk • detailed quantitative and qualitative analysis and assessment mapping of population movement (e.g. trade, migration, displacement, and travel and migration A sentinel event is information or an occurrence routes such as roads, lakes and rivers); of any nature, related or unrelated to polio, which • quantification of special high-risk or hard-to- suggests that the community or general geographic reach populations (e.g. geographic or cultural area may be at risk for a polio outbreak. Sentinel inaccessibility, areas of insecurity, vaccine refusals events can include: and sentinel events); 1. Appearance of vaccine-preventable disease • modelling of population immunity to relevant (e.g. measles, diphtheria, and/or VDPV of any outbreak/event poliovirus type(s); type) that suggests low routine immunization • detailed assessment of all surveillance indicators performance in general (e.g. measles) or at subnational level; polio-specific transmission risk due to mode of • mapping with geographic information system person-to-person spread (e.g. cholera); (GIS), with emphasis on high-risk populations, urban areas, border areas and regions difficult to 2. Rapid displacement or ongoing movement of access for any reason. under-immunized communities; 3. Detection of type 2 Sabin virus from a Ongoing analysis should use information from all biological or environmental source in the possible sources, including data beyond standard absence of mOPV2 use; polio programme information. Entities such as the International Organization for Migration, the United 4. Finding vials of tOPV or mOPV2 in Nations Office for the Coordination of Humanitarian the community. Affairs, and the WHO Health Emergencies Programme can provide critical information on Communities or administrative areas with sentinel population migration and insecurity. events should be included in the investigation and risk assessment.

RESPONDING TO A POLIOVIRUS 19 EVENT OR OUTBREAK Response standards – 6 overview

The scope of response to a detected event or outbreak Scope of vaccination. The scope of vaccination will be determined by the type and classification of campaigns will vary with the type of poliovirus event the poliovirus and the risk assessment. The key to or outbreak, the source of detection and the context. a successful response and interrupting transmission All outbreaks (VDPV or WPV) require a vaccination lies in adapting strategies as the situation evolves, response with an appropriate type-specific OPV over the course of the investigation and response. within 14 days of laboratory notification. In some circumstances, events in high-risk contexts may also warrant vaccination response, based on the Minimum response standards for risk assessment and discussion with country health poliovirus events and outbreaks authorities and GPEI technical experts. This includes Notification of a new poliovirus, or the spread of VDPVs pending classification or ambiguous VDPVs poliovirus to a new geographic area or population, (aVDPVs). requires national authorities and GPEI partners Isolation of an iVDPV requires careful assessment to be strongly engaged and rapidly initiate the to ensure that all household members and close following elements: community contacts are immunized with IPV. Larger- 1. Detailed investigation and risk assessment scale SIAs are not required unless circulation in the (see chapters 4 and 5) community is established. An iVDPV carrier should receive appropriate therapy for their underlying 2. Enhanced surveillance to increase sensitivity immune deficiency syndrome and be offered optimal and confidence that any ongoing person- anti-poliovirus treatment where available. to-person transmission of poliovirus will be rapidly detected (see investigation in chapters Figure 2. Core and enabling functions for 5 and 8) quality outbreak response 3. Planning of a vaccination response.

The core and enabling functions are illustrated in

Figure 2. Notify, investigate, Robust coordination, planning, budgeting, assess risk community engagement, and monitoring are Enhance surveillance enabling functions central to successful response. Enhance Assign surveillance Risk communication and social mobilization efforts grade and should be tailored to the event or outbreak context deploy Plan, support Vaccinate: budget and and support surveillance enhancement, vaccination reach every mobilize child response activities and routine immunization. For resources all outbreak and event responses, it is necessary A s to monitor and report all interventions and dvocat munitie e, communicate and mobilize com enhancements for surveillance, vaccination and communication (see Chapter 11). M ty onitor, evaluate and ensure quali

20 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK PLUS community non-household contact infected contact for household members for until two consecutive until two samples are negative are samples Clinical management Clinical with cVDPV response appropriate for primary for appropriate Examine monthly samples Examine monthly Immune disorder = iVDPV Immune disorder immunodeﬁ ciency condition immunodeﬁ IPV Treat as cVDPV and continue Treat and close community contacts community and close Low

2 Investigate Assess risk Assess No linked VDPV; No linked Further fi eld and fi Further sequencing results vaccination response vaccination no immune def. = aVDPV no immune def. Depends on local situation. Depends on local re-classifi ed and/or require ed and/or require re-classifi High and detections, virus may be and detections, Based on further assessment Based on further assessment “New” unclassified VDPV unclassified “New” scenario with linked with linked unlinked VDPVs VDPVs unlinked = high risk event Additional cases Additional cases VDPV = cVDPV or VDPV several clustered clustered several or other high risk ) 3

Notify, investigate, assess risk Enhance surveillanceEnhance OR High risk VDPV event

Assign surveillance 1 grade and Investigate Investigate Assess risk Assess deploy Plan, assessment support Vaccinate: budget and Outbreak response response Outbreak reach every mobilize within 8 weeks of day 0) within 8 weeks within 4-6 weeks of day 0) within 4-6 weeks child resources response OPV vaccination Continue w/ SIA 3+ if necessary Mop up (within 12 weeks of day 0) Mop up (within 12 weeks cVDPV Outbreak Large scale SIA1 (1-2 million children SIA1 (1-2 million children scale Large SIA2 (1-2 million children scale Large children < 5 years of age, within 14 days < 5 years children

A s 500 000 (200 000 to round Rapid response dvocat munitie e, communicate and mobilize com

M ty onitor, evaluate and ensure quali genetically linked to known cVDPV or previous aVDPV genetically linked to known cVDPV or previous surveillance (ES) sample or single human/acute flaccid paralysis (AFP) case not linked to known aVDPV by WHO HQ of VDPV2 genetic sequencing results Day 0, the day of receipt from all times are Figure 3: Response strategies following detection of an isolate of vaccine-derived poliovirus of vaccine-derived of an isolate detection following strategies 3: Response Figure 1 2 3

RESPONDING TO A POLIOVIRUS 21 EVENT OR OUTBREAK Response strategies following detection of an isolate The purpose of the grading is to: of vaccine-derived poliovirus are illustrated in • inform all partners of the nature of the event or Figure 3. outbreak, the response required and the need for Defining and planning high-quality outbreak mobilization of internal and external resources; response. A comprehensive outbreak response • activate GPEI response mechanisms; includes investigation, surveillance and vaccination, • prompt local government and GPEI partners at all all supported by communication and social levels to mobilize resources for support, including mobilization activities, including cross-border immediate human resources. coordination between countries. Coordinated and WHO will assign an outbreak Grade 1, 2 or 3 within high-quality activities will ensure confidence in the 72 hours of Day 0. A grade is valid for three to country’s ability to detect rapidly any poliovirus six months, through the first phase of outbreak circulation and to interrupt transmission through response, and should be reviewed with new vaccination. For surveillance, it is necessary to information and/or as response activities progress. monitor carefully both process (e.g. AFP reporting rates, lab performance) and outcomes (e.g. early The criteria used to grade outbreaks include: 1) the detection of virus through all surveillance strategies potential for transmission within the country and in high-risk special populations). beyond national borders based on the risk assessment (virologic, contextual, risk of international spread); Outbreak grading and 2) the strength of the country’s ability to respond to and contain the outbreak, including All outbreaks, and in some instances, events in high- vaccine management capacity. Depending on risk contexts, will be graded by WHO as per the circumstances, the risk assessment may include Health Emergency Response Framework.i discussion of the urgency and complexity of the event and the reputational risk it may generate. Grading is a procedure that triggers outbreak Country capacity is a subjective assessment based on response policies in WHO and the affected country health infrastructure and current security or access or countries. The grading will indicate risk level and challenges. Figure 4 presents a general risk matrix determine actions needed to manage the poliovirus for grading an event or outbreak. event or outbreak in the country context. See Chapter 10 for outbreak response scale-up and detailed information on GPEI support according to grading.

Figure 4: General risk matrix for grading an event or outbreak

Country capacity to respond Risk of local or international Strong Moderate Weak transmission Low Grade 1 Grade 1 Grade 2 Medium Grade 1 Grade 2 Grade 3 High Grade 2 Grade 3 Grade 3

i See “Emergency Response Framework (ERF)”. World Health Organization; 2017 (https://www.who.int/hac/about/erf/en, pg. 28, accessed 8 November 2018).

22 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Standard timelines for outbreak include multilevel calls with sub-regional outbreak response coordination offices, regional offices and global partners. Following initial consultation, operations Table 4 outlines key actions and timelines for event are supported by the GPEI Outbreak Preparedness and outbreak response (see Annex 2 for a detailed and Response Task Team (OPRTT) to manage list from Day 0 to close of outbreak). It is essential to coordination with all partners. rapidly establish coordination mechanisms between countries and GPEI partners at all levels. This may

Table 4. Major steps and timelines for critical components of event and outbreak response

Timeline Response actions for all isolates Within 24 hours Initiate investigation Country and each partner agency to initiate internal consultations Within 48 hours Initiate partner coordination via OPRTT1 Within 72 hours Country to notify WHO through IHR Risk assessment and grading mOPV2 Advisory Group and vaccine request (if applicable) Country to declare national public health emergency 72 hours to initiate Develop response plan for surveillance,2 vaccination and social mobilization OPRTT to coordinate and deploy RR team as required Within 14 days Rapid response vaccination (Round Zero) Within 90 days First large-scale, second large-scale, and a mop-up round Independent monitoring and LQAS results to Assess immunization quality: be shared within 14 days of each campaign • Independent monitoring required3 • LQAS4 to start as soon as possible Outbreak response assessments (OBRAs) 1. First assessment within three months of lab notification (Day 0) 2. Follow-up quarterly assessments 3. Final assessment after at least six months without poliovirus detection

1 OPRTT = Outbreak Preparedness and Response Task Team 2 See chapter 4 (Determining the geographic extent of transmission) and chapter 8 (Surveillance following investigation) 3 Independent monitoring does not replace, nor equal supervision 4 LQAS = lot quality assurance sampling

RESPONDING TO A POLIOVIRUS 23 EVENT OR OUTBREAK 7 Vaccination response

The primary objective of vaccination response is to 14 days of receipt of a laboratory sequencing result rapidly interrupt person-to-person transmission of (Day 0). It targets the immediate area of the virus poliovirus. Both the timing and the quality of the isolation, to stop further transmission rapidly (even vaccination response are critically important. To if the source remains unknown). accomplish virus interruption, a prompt vaccination response is required in a sufficiently large population The RR should be rapid, focused, and small and geographic scope. High-quality vaccination will scale; the intent should be to maximize quality protect individuals from poliovirus infection and in high-risk areas near the detection. If it cannot prevent future outbreaks if importation occurs. be conducted quickly (within three weeks), the country team may consider proceeding directly The oral polio vaccine appropriate to the poliovirus with SIA1 and its appropriate target population. strain induces intestinal mucosal immunity This decision should be made in consultation of and remains the vaccine of choice to interrupt GPEI partners. transmission rapidly and stop polio outbreaks. The most appropriate vaccine is selected with technical SIA 1 and SIA 2 j support from WHO and GPEI partners. Two high-quality large-scale vaccination campaigns (>90% of children vaccinated) should be completed Timing and scale of immunization within eight weeks of laboratory sequencing result (Day 0). The response will be tailored to the activities virus type and local context. The duration of the A four-step vaccination strategy has been endorsed campaign for SIA1 and SIA2 can be extended, or by GPEI for outbreaks and events in high-risk effort intensified in other ways, such as deployment contexts for all poliovirus types (types 1, 2 and of additional personnel and supervisors, to complete 3) (see Figure 5). The response consists of rapid the campaign and reach missed children in areas of response, SIA1, SIA2, and a mandatory targeted poor performance, as identified by intra-campaign mop-up round, with the option for further SIAs if monitoring or supervisor observations. justified by breakthrough isolates, cases or other evidence of ongoing transmission. Mop-up round or additional SIAs A mop-up round is required as an additional step The aim of this strategy is to ensure: 1) a timely wherever monitoring suggests children have been response; 2) two high-quality large-scale rounds; missed in certain health districts or areas, to ensure 3) re-vaccination of all areas where quality was interruption of transmission (even in the absence insufficient; and 4) removal of all mOPV2 from the of new poliovirus detections). Information to field as soon as possible (for type 2 response only). guide the selection of districts for full mop-up can include: intra-campaign monitoring, independent A rapid response (RR) vaccination campaign monitoring, eyewitness accounts and spot checks, For an outbreak or high-risk event, a RR vaccination LQAS, post-campaign surveys, or new events campaign is the first vaccination response within such as population movements, and breakthrough

j See “15th Meeting of the Strategic Advisory Group of Experts (SAGE)” Polio Working Group, April 2018 – Conclusions and recommendations, Note for the Record. Geneva: World Health Organization;

24 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Figure 5. Visual representation of timing and scale of immunization activities required

Rapid Mop-up Response SIA 1 SIA 2 Round

Intensiﬁ cation or extension of campaign activities before the end of SIA 1 and SIA 2 to sweep or “mop up” areas of poor performance as identiﬁ ed during the campaign.

cases. A mop-up round should be included in the case-by-case through a detailed risk assessment, initial outbreak response plan, appropriately scaled informed by discussion with technical experts (i.e. and implemented after SIA2, and only cancelled epidemiologists, virologists and country experts), to if ALL health areas demonstrated high-quality ensure that all high-risk zones are reached. implementation and vaccination coverage. The target population must be within the capacity of Where quality is clearly inadequate in a large the programme to attain high coverage. Depending geographic area, break-through isolates are on the local context and capacity, phasing of identified or the outbreak continues to spread campaigns may be considered to ensure quality in to unvaccinated areas, additional SIAs should be each geographic and demographic region covered. considered and planned. Target age-group Two campaigns must be completed after the last detected virus. A high-quality mop-up round may For SIAs are children less than five years of age. be considered as one of these campaigns, if the area An expanded age group (up to 10 or 15 years, or of the detected virus was covered twice. the whole population depending on local context) should be considered if there is evidence of virus circulation among older age groups. Target population Type 1 and Type 3 events or outbreaks: The Short-interval campaigns first RR (or Round Zero) can be 200 000 to 500 The interval between SIA rounds can be as short 000 children, and approximately 2 million for as one week. This applies regardless of the type subsequent larger scale rounds. of OPV used. For example, an mOPV2 campaign could be followed one week later with an additional Type 2 events or outbreaks: The first RR round of mOPV2 or bOPV where needed. A short (or Round Zero) can be 100 000 to 400 000 interval additional dose (SIAD) strategy may be children, and approximately 1–4 million for used in special circumstances when there are subsequent larger scale rounds. See Tables 5 multiple circulating polioviruses and/or when short and 6 for more information. windows of access or opportunity to vaccinate arise It is possible to consider increasing the scope further, (e.g. mobile or hard-to-access children). Response in densely populated areas, or if there is evidence of, strategies recommended for OPV using countries for or potential for, extensive circulation (e.g. outbreak each type of poliovirus type are outlined in Table 5 population well connected to a major urban area). (events) and Table 6 (outbreaks). The geographic scope for response is assessed

RESPONDING TO A POLIOVIRUS 25 EVENT OR OUTBREAK Routine immunization Type 2 poliovirus response Strengthening routine immunization (RI) remains a For type 2 events or outbreaks, when the use of central pillar of polio eradication. Vaccination with mOPV2 is necessary to protect children from bOPV/IPV and other antigens must continue as usual paralysis and stop transmission, it is even more and be further strengthened, even if immunization critical to respond quickly, and then ensure high sessions are conducted on the same day as, or within quality in larger scale and mop-up rounds. As type days of, an outbreak response. Strategies to mitigate 2-containing OPV is no longer used in RI, mOPV2 any negative impact of outbreak response on the mop-up rounds are a final opportunity to ensure conduct of RI should be planned in advance (e.g. mucosal protection against type 2 poliovirus. if staff are diverted for the SIA efforts, immediate rescheduling of RI sessions).

Box 2. • Type 2 poliovirus now spreads rapidly due to waning type 2 immunity. In WPV1 endemic countries, response to cVDPV2 must be immediate. • During concurrent outbreaks of cVDPV2 and cVDPV1 or cVDPV3, immediate cVDPV2 response also takes precedence • Co-administration of mOPV2 and bOPV is not recommended during campaigns for operational reasons • A polio event or outbreak in a country that has been using only IPV in the RI programme requires immediate consultation with WHO, as for any polio event or outbreak anywhere • Regardless of outbreak response plans, routine bOPV and IPV immunization must continue without a break

26 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Time frame In high-risk First scenario: SIA within followed 14 days by successive high coverage campaigns , additional however in an area without mOPV2 use within the last 12 without mOPV2 use within the last in an area , requires an immediate rapid response (RR) high quality SIA1, response rapid an immediate , requires Target age 0–5 years Target mOPV2 vaccine 1–2 million children approx. Targeting WHO Director-General to request Vaccine age 0–5 years Target mOPV2 vaccine 100 000–400 000 children approx. RR targeting may < 2 million children to be reduced SIAs 1 and 2 may for Scope 100 000 – 400 children, to be reduced is if there be conducted should scope SIAS with increased (i.e cVDPV2) of transmission evidence as required target Mop-up round WHO Director-General to request Vaccine

------Immunization response situation, as advised depends on local SIAs plan and implementation by WHO and GPEI partners situation depends on the local SIAs plan and implementation high two plan for high risk. In high-risk scenario, No SIAs unless quality SIA rounds situation depends on the local SIAs plan and implementation of a VDPV2 Detection months SIA2 and mop-up round Community search for for Community search of virus and evidence cases transmission population immunity Assess surveillance Enhance assessment response Event if SIAs conducted for Community search of virus and evidence cases transmission population immunity Assess surveillance Enhance assessment response Event if SIAs conducted and social Epidemiological investigation for Community search of virus and evidence cases transmission population immunity Assess surveillance Enhance GPEI advises on virological risk IPV routine Strengthen immunization assessment response Event if SIAs conducted General response General • • • • • • • • • • • • • • • Source Environment Environment (with no of evidence individual excreting virus) Human or Environment

in an on) olati Isolate WPV WPV 1 or 3 WPV 2 VDPV VDPV2 (new unrelated is without area mOPV2 use within the last 12 months Table 5. Event response strategies by poliovirus type by poliovirus strategies response 5. Event Table

RESPONDING TO A POLIOVIRUS 27 EVENT OR OUTBREAK Time frame Intravenous immunoglobulin for case (+ monoclonal antibodies or (+ monoclonal case for immunoglobulin Intravenous if available) anti-virals contacts community and close members household IPV for

- - Immunization response situation depends on the local SIAs plan and implementation deemed unless response vaccination an immediate require Does NOT in a high-risk scenario be found to not required SIAs are be considered SIAs may be considered SIAs may Epidemiological and social Epidemiological investigation for Community search of virus and evidence cases transmission population Assess immunity surveillance Enhance GPEI advises on virological risk IPV routine Strengthen immunization assessment response Event if SIAs conducted and social Epidemiological investigation and social Epidemiological investigation for Community search of virus and evidence cases transmission population immunity Assess surveillance Enhance Assessment Response Event if SIAs conducted and social Epidemiological investigation for Community search of virus and evidence cases transmission population immunity Assess surveillance Enhance Assessment Response Event if SIAs conducted General response General • • • • • • • • • • • • • • • • • • Source Human or Environment Human Human or Environment Human or Environment in Isolate VDPV2 (new unrelated isolation) with an area 2 at least mOPV2 SIAs in conducted 12 the last months iVDPV2 VDPV1 or 3 (pending classification) aVDPV1 or 3

28 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK

Time frame Campaign timing from Day 0 Day Campaign timing from (lab sequencing result) Within 14 days is critical Timeliness Within 28 days Within 6–8 weeks within three Mop-up round of initial months (90 days) in virus sequencing results, all health zones not meeting quality standards Vaccine Vaccine mOPV2 WHO to Request General Director- mOPV2 through Advisory Group mOPV2 mOPV2 mOPV2 Age group 0–5 years 0–5 years 0–5 years 0–5 years Campaign scope Approximately. 100 000 to 400 000 children 1–4 At least million children, all consider zones at risk 1–4 At least million children, all consider zones at risk As required Immunization response not required SIAs are be high risk scenario deemed to unless not required SIAs are 1 2 Epidemiological and social Epidemiological investigation and social Epidemiological investigation population immunity Assess surveillance Enhance General response General • • • • Campaign strategy (RR) response Rapid risk zone immediate Small geographic epicentre) (outbreak SIA 1 High quality microplanning SIA 2 With further quality improvements Mop-up round zones not meeting in all areas/health Required < 90%, failed e.g. coverage quality standards: in SIA1/2 children missed LQAS, Source Human Human or Environment four (over months since mOPV2 last in response immediate area)

Isolate iVDPV1 or 3 Sabin 2 Sabin-like virus type Outbreak cVDPV cVDPV2 Human or environment area infected Newly without or in an area mOPV2 use within 6 months the last Table 6. Outbreak response vaccination by poliovirus type for OPV-using countries type for by poliovirus vaccination response 6. Outbreak Table

RESPONDING TO A POLIOVIRUS 29 EVENT OR OUTBREAK

Campaign timing from Day 0 Day Campaign timing from (lab sequencing result) Ongoing GPEI and mOPV2 consultation Advisory Group and scope strategy review to Within 14 days is critical Timeliness Within 28 days Within 6–8 weeks within three Mop-up round of initial months (90 days) in virus sequencing results, all health zones not meeting quality standards Within 14 days is critical Timeliness Within 28 days Vaccine Vaccine mOPV2 bOPV bOPV bOPV bOPV bOPV bOPV

Age group 0–5 years 0–5 years 0–5 years (or expanded if age group warranted) 0–5 years 0–5 years 0–5 years 0–5 years

Campaign scope reduced Scope < 2 million to children Approximately 200 000 to 500 000 children 2 million children, all consider zones at risk 2 million children, all consider zones at risk As required and scope strategy review to Ongoing GPEI consultation Minimum 500 000 children Minimum 2 million children, allconsider zones at risk 3 3 1 1 conduct at least two additional two at least conduct 2 Campaign strategy in cases or breakthrough Additional detections than 2 mOPV2 SIAs, within the with more areas 6 months, last SIAs completed SIAs or as needed until two detection poliovirus the last after (RR) response Rapid risk zone immediate Small geographic epicentre) (outbreak SIA 1 High quality microplanning SIA 2 With further quality improvements Mop-up round / health zones not meeting in all areas Required < 90%, failed e.g. coverage quality standards: in SIA1/2 children missed LQAS, or expanded mop-up round targeted Further within 120 days not stopped SIAs if outbreak SIAs completed SIA3/SIA4 as needed until two detection poliovirus the last after (RR) response Rapid risk zone immediate Small geographic epicentre) (outbreak SIA 1 High quality micro-planning Outbreak virus type Outbreak cVDPV2 Human or environment Breakthrough isolation cVDPV1 or 3 Human or environment WPV WPV 1 or 3 Human or environmental

30 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK

Campaign timing from Day 0 Day Campaign timing from (lab sequencing result) Within 6–8 weeks within 3 Mop-up round months of initial virus (90 days) in all sequencing results, health zones not meeting quality standards Within 14 days is critical Timeliness Within 28 days Within 6–8 weeks within three Mop-up round of initial months (90 days) in virus sequencing results, all health zones not meeting quality standards Vaccine Vaccine bOPV bOPV mOPV2 WHO to Request General Director- mOPV2 through Advisory Group mOPV2 mOPV2 mOPV2 Age group 0–5 years 0–5 years 0–5 years 0–5 years 0–5 years 0–5 years

Campaign scope Minimum 2 million children, allconsider zones at risk As required and scope strategy review to consultation Ongoing GPEI and mOPV2 Advisory Group Approximately 200 000 to 500 000 children 1–2 At least million children, all consider zones at risk 1–2 At least million children, all consider zones at risk As required 3 Small geographic Small geographic 1 2 2 Campaign strategy SIA 2 With further quality improvements Mop-up round / health zones not meeting in all areas Required < 90%, failed e.g. coverage quality standards: in SIA1/2 children missed LQAS, or expanded mop-up round targeted Further within 120 days not stopped SIAs if outbreak SIAs completed SIA3/SIA4 as needed until two detection poliovirus the last after (RR) response Rapid epicentre) risk zone (outbreak immediate SIA 1 High quality microplanning SIA 2 With further quality improvements Mop-up round zones not meeting in all areas/health Required < 90%, failed e.g. coverage quality standards: in SIA1/2 children missed LQAS, Outbreak virus type Outbreak WPV 2 Human Depends situation on local and whether a breach containment is identified or of re-emergence source unknown

RESPONDING TO A POLIOVIRUS 31 EVENT OR OUTBREAK

isolate.

investigated.

Campaign timing from Day 0 Day Campaign timing from (lab sequencing result) Vaccine Vaccine Age group priority.

Campaign scope and scope strategy review to consultation Ongoing GPEI and mOPV2 Advisory Group and mOPV2 Advisory Group Consult with WHO, GPEI partners and mOPV2 Advisory Group Consult with WHO, GPEI partners 3 Campaign strategy or expanded mop-up round targeted Further within 120 days not stopped SIAs if outbreak SIAs completed SIA3/SIA4 as needed until two detection poliovirus the last after check immunization or AFP case: WPV infection person/ exposed OPV/IPV to and give status; contacts and close family, case, response broader options for Review with emphasis on possible Investigate depends on response breech; containment many factors

k A rapid response (RR) round is also sometimes referred to as Round Zero to emphasize that speed is the first to as Round Zero is also sometimes referred (RR) round A rapid response newly groups, by purposeful independent monitoring in hard-to-reach (e.g. as revealed persistently missed children if evidence of less than 90% coverage, failed LQAS (90% threshold), is required A mop-up round area of the last detected poliovirus the if the latter covered round may suffice For example, in specific situations, an SIA and a mandatory mop-up The scale and scope of SIAs will depend on local circumstances. to Live Polioviruses: Interim guidance in managing exposed persons for countries hosting facilities that maintain live polioviruses” on GPEI website library; See “Public Health Management of Facility-Related Exposure discovered villages, or chronic refusals) or any other evidence suggesting inadequate campaign reach or quality. Anecdotal information suggesting vaccination gaps must be fully or quality. or any other evidence suggesting inadequate campaign reach refusals) villages, or chronic discovered http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/gpei-tools-protocols-and-guidelines/. Outbreak virus type Outbreak WPV2 breach Containment Consult guidance public health for management of facility-related live to exposure polioviruses WPV 2 Environment 1 2 3 k

32 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK High-quality campaigns no prior SIAs, inaccessible or mobile populations). See Microplanning Guidelinesl and Best Practices Consistent with the performance targets of the in Microplanning for Polio Eradicationm to guide SOPs, all polio outbreaks and any type 2 polio development of micro plans. event at high risk of rapid expansion require RR vaccination within 14 days of notification, followed Preparedness monitoring. A preparedness by implementation of high-quality vaccination dashboard and/or a checklist and timeline are campaigns (i.e. SIAs). In implementing the four- required to track country readiness to launch SIAs step vaccination strategy for outbreak response, a and support quality implementation. Detailed tension exists between achieving a timely response pre-campaign readiness and intra-campaign (i.e. within 14 days) and achieving the desired quality monitoring are expected for all vaccination vaccination coverage (>90%). In settings where responses. Resources to support preparedness poliovirus is detected, the RR (Round 0) may not monitoring are available. meet all quality expectations (e.g. situations with security or access challenges, operational difficulties, Campaign monitoring. A high-quality campaign hard-to-reach subpopulations and/or vaccine must aim for coverage of >90% for SIA1 and SIA2 hesitancy, or simply lack of adequate time to plan). with no persistently missed children. Intra- and This is acceptable as long as the response is timely. post-campaign monitoring is essential to ensure quality of SIAs in all phases. All sources of intra- However, quality campaigns are essential to and post-campaign data must be reviewed and interrupt transmission of poliovirus from child to triangulated to assess the quality of the campaign, child. Therefore, it is critical to ensure that the first including but not limited to: and second large-scale vaccination rounds (SIA1 and SIA2) reach every child. Reaching every child • administrative coverage is particularly important when using mOPV2 due • rapid intra-campaign monitoring, convenience to rapidly declining type 2 mucosal immunity surveys and spot checks everywhere since withdrawal of tOPV. • Independent monitoring: house-to-house and out-of-house (market surveys) monitoring Quality microplanning, preparedness monitoring, • clustered LQAS and intra- and post-campaign monitoring are • overall consistency of data sources essential strategies to prepare and achieve high- • ongoing and new population movements quality campaigns. • vaccine management, monitoring and reporting of vaccine wastage, doses remaining, number of Quality microplanning. Preparation of macro- vials unaccounted for (especially for mOPV2) level plans and budgets based on the target • observations of campaign personnel, supervisors, population, local conditions and operational monitors, and observers in the field. costs allows stakeholders to discuss strategies and secure resources. Such top-down planning must For any areas or populations where suboptimal rapidly be accompanied with effective bottom-up campaign planning and implementation are microplanning (i.e. developing and validating plans identified (e.g. coverage <90%, persistently missed at the community level). Training and supportive children, vaccine hesitancy/refusal), mop-up supervision help ensure that micro plans are of vaccination must be rapidly carried out. Further high quality. Innovations such as GIS imagery are details of monitoring approaches are provided in useful to validate plans in challenging or hard-to- Best Practices for Monitoring the Quality of Polio reach contexts (e.g. densely populated urban areas, Eradication Campaign Performancen and below remote settlements with weak documentation or in chapter 11.

l See “Microplanning Guidelines”. GPEI guidance. Geneva: Global Polio Eradication Initiative; 2011 (see document within GPEI library http:// polioeradication.org/tools-and-library/resources-for-polio-eradicators/gpei-tools-protocols-and-guidelines/, accessed 8 November 2018). m See “Best practices in microplanning for polio eradication”. GPEI guidelines. Geneva: Global Polio Eradication Initiative; 2018 (http://polioeradication. org/wp-content/uploads/2018/08/best-practices-20180810-03.pdf, accessed 8 November 2018). n See “Best Practices for Monitoring the Quality of Polio Eradication Campaign Performance”, GPEI guidelines. Geneva: Global Polio Eradication Initiative; 2018 (http://polioeradication.org/wp-content/uploads/2018/08/best-practices-20180810-03.pdf, accessed 8 November 2018).

RESPONDING TO A POLIOVIRUS 33 EVENT OR OUTBREAK Planning for mobile, hard-to-reach Examples include: and special populations i) A type 2 poliovirus event or outbreak with concurrent endemic WPV1 transmission. Special populations are groups that are underserved Both bOPV and mOPV2 are required. The or not served by the regular health system for two campaigns may take place separately two reasons such as insecurity, inadequate infrastructure, weeks apart (or less if operationally feasible). and/or access barriers. Population groups may be For example, one mOPV2 SIA could be followed mobile (e.g. economic migrants, internally displaced 10 to 14 days later by one bOPV SIA. Use of persons, refugees, nomadic populations) or mOPV1 may exceptionally be considered. stationary (e.g. remote, hard-to-reach communities, such as fisherman or islanders, or urban hard- ii) Ongoing transmission of two cVDPVs, to-reach populations, such as those who live in such as cVDPV1 or cVDPV3 with cVDPV2. informal settlements, religious communities, or Response to cVDPV2 takes priority. Rounds of who are members of marginalized groups). All mOPV2 and bOPV might be staggered based on aspects of outbreak response, including surveillance, operational feasibility. immunization and communication strategies, must Response strategy decisions will be made based on be tailored to reach special populations. careful review of the epidemiology, the geographical Strategies for special populations should be areas affected, the capacity for robust response, and developed in conjunction with community leaders, vaccine availability. communication and social mobilization experts, and personnel knowledgeable of the context, as Integration with other health well as service providers with special expertise (e.g. non-governmental organizations (NGOs), interventions public services, women’s groups, faith-based During outbreak response planning, consideration organizations). Appropriate strategies to vaccinate can be given to integrating with other health every child may require creative thinking, and interventions (e.g. measles campaign already planned, could include tactics such as transit posts, hit-and- vitamin A, etc.) in the following circumstances: run teams, market vaccinations, and/or combined • Full discussion with all partners takes place at outreach with veterinary or animal vaccinations or country and other relevant levels. other special strategies. • Following types 1 and/or 3 outbreak response: RR, All strategies and tactics must be well documented SIA1 and SIA2 rounds were successfully to ensure that data on the number of children implemented. Subsequent risk mitigation vaccinated, appropriate vaccine management, and rounds could consider integration as a cost- other relevant information is collected. saving measure. • During type 2 outbreak response: Additional opportunity available to offer bOPV in the Concurrent circulation of different midst of a type 2 outbreak, appropriate if bOPV poliovirus types campaign would otherwise be deferred, so as not to allow the type 2 response activities to compete If polioviruses of different types circulate with bOPV risk mitigation and generate types 1 concurrently, the response to type 2 poliovirus and 3 immunity gap. takes precedence, as type 2 immunity is waning • Plans are in place to secure high quality globally. Detailed response plans should be reviewed intervention for all antigens considered. on a case-by-case basis in consultation with GPEI • Monitoring mechanisms are agreed upon technical experts. in advance.

34 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Inactivated polio vaccine (IPV) For any outbreak or high-risk event that may require a vaccination response, the country must submit a IPV provides a high-level of individual immunity vaccine request for mOPV2, signed by the national and protection against paralysis. IPV does not authorities, within 72 hours of the type 2 poliovirus induce mucosal immunity in persons without sequencing result (Day 0). The Advisory Group prior OPV immunization for the corresponding will rapidly review the risk assessment and vaccine serotype. In a child infected with poliovirus request and recommend a course of action to the without previous OPV vaccination, IPV does WHO Director-General. not stop onward transmission of the virus. Conversely, IPV boosts mucosal immunity in Upon approval, the mOPV2 vaccine stock with the those with prior OPV exposure . shortest shelf life will be released by UNICEF from the global stockpile for immediate use. (See vaccine In specific instances, IPV may be used as a part of request form and template for approval of import, immediate response actions, with scope and age on the GPEI websitep). group to be determined by local circumstances and following discussion with GPEI partners IPV requests Where IPV campaigns are deemed to be of benefit, fractional-dose IPV (fIPV) should be Any country considering use of IPV in SIAs implementedHealth worker training materials should fully justify this in the risk assessment for fIPV administration are available. and response plan. An IPV response plan should provide rationale, target geography and population, vaccination delivery strategy Requesting vaccine preferences, preparedness interventions for effective use of vaccine, monitoring and bOPV requests evaluation plans and estimates of the operations Vaccine requests for bOPV follow usual procurement costs. This plan should be supported by the procedures through the United Nations Children’s National Technical Advisory Group or its Fund (UNICEF). equivalent, endorsed by the National Inter- Agency Coordination committee or its equivalent mOPV2 requests before submitted to GPEI/GAVI for funding. In line with the World Health Assembly resolution,o Approvals will be on an exceptional basis only, in specifi procedures are in place to access or use line with local circumstances, in-country stock mOPV2. Countries must present a risk assessment and global IPV supply availability. The country and vaccine request for consultation by the Advisory can also request supplies/devices for intradermal Group on mOPV2 Provision(Advisory Group). Only administration of fIPV(e.g. 0.1ml syringes and/ or adaptors). the WHO Director-General can authorize release of mOPV2 from the global vaccine stockpile, or use of in-country remaining mOPV2 stocks, upon the recommendation of the Advisory Group.

o See “Resolution WHA68. Poliomyelitis. In: Sixty-eighth World Health Assembly”, pg. 10. Geneva: World Health Organization, 26 May 2015. (http://apps. who.int/gb/ebwha/pdf_files/WHA68-REC1/A68_R1_REC1-en.pdf#page=1, accessed 8 November 2018). p See “mOPV2 Vaccine Request Form”. (Document within GPEI library (http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/gpei- tools-protocols-and-guidelines/, accessed 8 November 2018)

RESPONDING TO A POLIOVIRUS 35 EVENT OR OUTBREAK Vaccine management and reporting Routine immunization: Recovery Vaccine management is integral to ensuring a high- and strengthening quality vaccination campaign and of paramount The backbone of polio eradication and outbreak importance at all levels and at all stages of the response remains routine immunization (RI) response. The movement of any vaccine used in against polio in line with the national childhood outbreak response must be monitored. All vaccine immunization schedule. In general, cVDPV received, distributed, and administered must be outbreaks occur in areas with sub-optimal recorded, through for example, stock management routine immunization coverage. Although tools and/or vaccine utilization records. All vials and priority must be given to achieving high-quality doses used, partially used or unused, must be fully vaccination, polio surge resources can be tasked recorded (whether due to partial use, contamination, with supporting RI recovery as soon as possible. or vaccine vial monitor changes) and vials returned Immunization recovery should begin during the must be fully accounted for each SIA. outbreak response period, maximizing use of surge capacity to strengthen programme management, A reverse logistics and vial disposal plan must be microplanning, community mobilization and integrated with the outbreak response plan outlining: performance monitoring. It is also critical to build that health facilities and district vaccine stores will on the political attention resulting from the cVDPV be left with a one-month supply (except for all to ensure accountability for routine immunization mOPV2, which is immediately withdrawn); service delivery. The Emergency Operations Centre (EOC) in collaboration with EPI should effectively how excess unused vaccine will be returned to maximize the benefit of time-limited support to central or regional storage in a reverse cold chain; RI, through a thorough analysis of the reasons for low immunization coverage in the outbreak areas (for mOPV2 only), how all vials will be returned followed by selected short and medium-term to safe disposal sites (used, partially used, unused, immunization systems strengthening actions in line vials discarded due to vaccine vial monitor changes with the operational components of the Reaching or contamination). Every District (RED)r approach, namely:

For all mOPV2 campaigns and mop-up rounds, 1. Optimization of immunization services it is of critical importance that every vial and (focus on expansion and re-establishment dose of unused vaccine is accounted for and of outreach) withdrawn to central storage in a safe and secure 2. Supportive supervision for immunization manner. Reporting on the status of vaccine used, quality assurance retrieved and in storage is required after each and every SIA, including the immediate RR. All 3. Linking immunization services with lost and missing vials must be reported.q communities 4. Monitoring and use of data for action 5. Effective planning and management of immunization resources.

q See: Technical Guidance for mOPV2 vaccine management, monitoring, removal and validation. Geneva: Global Polio Eradication Initiative; 2016 (http:// polioeradication.org/wp-content/uploads/2016/11/Technical-guidance-mOPV2-management-monitoring-removal-and-validation_Oct2016_EN.pdf, accessed 8 November 2018). r See: Technical Guidance for mOPV2 vaccine management, monitoring, removal and validation. Geneva: Global Polio Eradication Initiative; 2016 (http:// polioeradication.org/wp-content/uploads/2016/11/Technical-guidance-mOPV2-management-monitoring-removal-and-validation_Oct2016_EN.pdf, accessed 8 November 2018).

36 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Surveillance following 8 investigation

Guidelines for routine poliovirus surveillance, A key objective of AFP surveillance, following including AFP and environmental surveillance, are identification of an event in a high-risk area or outlined in other GPEI documents, including; Best any outbreak, is to achieve an annualized rate of Practices in Active Surveillance for Polio Eradications, greater than three non-polio AFP cases per 100 000 and the Global Polio Surveillance Action Plant. (While children, younger than 15 years of age, in every Chapter 4 (above) outlines the initial surveillance subnational division equivalent to a district, for at steps required as part of a thorough investigation, the least 12 months after the last case or isolate. While current chapter focuses on surveillance enhancement districts with fewer than 50 000 children under following initial investigation. 15 years of age may not detect AFP every year, the quality of AFP surveillance should be checked for any silent district regardless of population size. Surveillance enhancement Following the initial investigation of any polio event Countries are to undertake the following activities or outbreak, it is critical to assess and enhance to enhance AFP surveillance: poliovirus surveillance. Vigorous effort is required to • Immediately notify all national and subnational put the surveillance system on high alert and improve surveillance units about the poliovirus event/ sensitivity to identify promptly any new virus, AFP outbreak. cases, or ongoing transmission, even outside the • Rigorously sensitize all health care workers to immediate outbreak zone. The outbreak response AFP surveillance and notification requirements, plan must include surveillance initiatives from Day including zero-reporting. 0 of the event/outbreak, continue surveillance in • Review and reclassify reporting sites (if required) parallel with other aspects of the response, and in the AFP active surveillance network within the maintain selected supplemental strategies for six immediate outbreak zone and of neighbouring months or more after the last detected poliovirus.

Box 3. The goal of surveillance during a poliovirus high-risk event or outbreak is to increase sensitivity to detect any poliovirus. To achieve this it is also necessary to ensure proper data management and to meticulously document activity and performance indicators.

An outbreak surveillance plan should include steps for the ongoing review of timeliness and completeness of reporting sites in the AFP surveillance network (both AFP and ES), monitoring active case search, mapping populations not covered by the surveillance network, and raising awareness of surveillance needs among health care providers and the community. All national and international resource requirements (human, financial and logistical) should be included in the plan.

s See “Best practices in Active Surveillance for Polio Eradication”, 2018. GPEI guidelines. Geneva: Global Polio Eradication Initiative; 2018 (http:// polioeradication.org/wp-content/uploads/2018/08/best-practices-20180810-01.pdf, accessed 8 November 2018). t See “The Global Polio Surveillance Action Plan (2019–2020)” 2019. GPEI guidelines. Geneva: Global Polio Eradication Initiative (http://polioeradication. org/tools-and-library/resources-for-polio-eradicators/gpei-tools-protocols-and-guidelines/).

RESPONDING TO A POLIOVIRUS 37 EVENT OR OUTBREAK districts (high-risk areas) and ensure that Environmental surveillance secondary and tertiary health facilities are fully involved in AFP surveillance. Environmental surveillance (ES) serves as a • Ensure that supplemental AFP case-finding complement to AFP surveillance, but never as a strategies are in place in the outbreak zone substitute. It is the monitoring of wastewater or and high-risk areas, including ad hoc active sewage from designated locations to detect the search during campaigns by vaccination teams, presence of poliovirus. In the context of events independent monitors, and LQAS survey teams. and outbreaks, ES can provide information on • Monitor and document that at least 90% of all the geographic extent and duration of poliovirus planned active surveillance visits are conducted. circulation, as well as the excretion of polio vaccine • Consider supplemental strategies, such virus following vaccination. as enhancing environmental surveillance, At the outset of a new event or outbreak, the in consultation with national and GPEI following actions should be put in place surveillance experts. • Ensure the national laboratory is involved • Assess the performance of all existing ES sites in in outbreak planning and that capacity is the area. strengthened to handle additional workload and • Increase the frequency of specimen collection to maintain rapid specimen handling. every two weeks, where feasible, for a minimum of six months following the most recent isolate detected or the most recent use of mOPV2, whichever is later. • Consider new collection sites within and outside the outbreak or event area, where technically appropriate and laboratory capacity allows. • Assess nearby urban areas with a population of 100 000 or more as candidates for new or enhanced environmental sampling.

Figure 6. Decision process for enhancement of environmental surveillance following a new VDPV2 isolation

Yes No Change in # Sites, Frequency Yes Adequate? No • Increase sample collection frequency to every two weeks immediately and/or, • Consider an increase in the number of sites following assessment by the New VDPV ES In Regional Office (RO) and partners Isolation place? I. Immediate: Assess feasibility and need of ES deployment (Within 2 weeks of type-2 poliovirus Isolation), by RO and partners.

II. If feasibility/need is confirmed, conduct ES screening from No at least 3 different sites biweekly (Ideally within 2–4 weeks of every response) and continue for ≥ 6 months after last mOPV2 vaccination campaign

III. Use a method of sampling depending on assessment of local factors, feasibility of sample shipment, reference laboratory capacity, and epidemiologic situation

Source: Polio Environmental Surveillance Enhancement Following Detection of Vaccine-Related Type-2 Poliovirus. 9 May 2018

38 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Any proposal to scale up ES must consider laboratory 4. Selectively use other supplemental strategies capacity to support the effort, and not jeopardize that are usually only part of an initial field AFP surveillance. Detailed guidelines on polio investigation. Given the relatively low yield environmental surveillance enhancement following and high resource needs of these strategies detection of vaccine-related type 2 poliovirus is when used in the long term, they should available, from which Figure 6 is drawnu. only be considered in consultation with GPEI partners and laboratory counterparts. Strategies for special populations • Contact sampling in high-risk, security- compromised or hard-to-reach populations and security-compromised areas may exceptionally be advised for every AFP Supplemental surveillance strategies may be required case for a limited time only, such as, for in circumstances involving highly vulnerable example, in recently accessed areas. As an populations (e.g. nomads or other populations ongoing surveillance strategy, ongoing contact who do not routinely access health services) and/or sampling can be maintained for no longer inaccessible areas beyond the routine reach of even than six months. enhanced health or surveillance services. Activities • Once transmission has been demonstrated in will need to be tailored to the specific situation, but an area, healthy children surveys are no longer consider the following approaches: necessary and not recommended. However, such surveys may occasionally help assess 1. If not already in place, identify community possible outbreak expansion (e.g. into other leaders or healers, including women, as focal geographic areas where poliovirus may be points and provide the training and tools to circulating undetected by AFP surveillance, facilitate access to and reporting of suspect or along transit routes of mobile groups). In AFP cases. exceptional situations, a stool survey may 2. Increase community sensitization to polio be a screening tool for groups moving from and AFP surveillance, using culturally an event/outbreak area to a new area (e.g. appropriate tools. internally displaced populations, refugees). 3. Leverage innovative partnership with other 5. If poliovirus is found in a high-risk mobile groups or services with access to special population (e.g. internally displaced populations (e.g. other government ministries populations, refugees, or nomads), or in an or departments, other United Nations area frequented by populations on the move, organizations, NGOs, civil society groups, then immediately assess surveillance sites veterinarians, etc.). along known migration routes to seek evidence of transmission.

u See "Polio Environmental Surveillance Enhancement Following Detection of Vaccine-Related Type-2 Poliovirus." 2018. Geneva: Global Polio Eradication Initiative (http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/gpei-tools-protocols-and-guidelines).

RESPONDING TO A POLIOVIRUS 39 EVENT OR OUTBREAK Communication and 9 social mobilization

Communication for Development (C4D) is a Strategic C4D framework for polio systematic, planned and evidence-informed strategy to promote positive and measurable behaviour outbreak response and social change. Effective social mobilization, Immediate C4D outbreak response communication with emphasis on high-risk populations, is a key is initiated as soon as an outbreak is declared and component of polio outbreak response. The polio should be integrated in all aspects of planning and C4D outbreak response approach is designed to responding to an outbreak or high-risk event. The redress perceptions and social norms that deter outcome of the joint epidemiological and social caregivers from vaccinating their children, and investigation of the infected case/area is critical rebuild commitment to vaccination, including to understand the social environment for areas or routine immunization. groups affected by the virus. Interventions should be based on understanding of all relevant social barriers A strong communication strategy will strengthen and promote vaccination. (See Strategic Framework performance of all response activities, increase within the Communication for Development uptake of vaccination in all population groups, Guidelines for Responding to Polio Events and and support robust surveillance with early Outbreaks for detailed guidancev). notification of AFP. At this phase, the focus is on building (or Critical C4D steps include: rebuilding) caregivers’ critical awareness about • raising awareness of campaign dates polio, OPV and the fact that there is an outbreak • strengthening community perception of in the community that puts children at risk. The vaccination through building trust in health primary goal is to raise awareness of the outbreak to worker capacity, vaccine safety and efficacy at least 90%. Communication approaches should be • elevating perception of polio risk straightforward, clear and elicit an urgent response • addressing bottlenecks in the decision to vaccinate. from parents and the community at large.

In the context of vaccine-derived poliovirus, Plans for subsequent campaigns, including SIA1, communication of risk is particularly challenging, SIA2 and a mop-up round, should include C4D especially when the virus is detected only in the interventions to reach missed children and reduce environment. While the C4D outbreak response for refusals. Activities should continue to elevate public VDPVs follows the same principles as for WPV, it is risk perception of the outbreak and its impact, important to reinforce vaccine safety messaging and especially for non-compliant groups or communities. address any context-specific fears or misconceptions For campaigns using the SIAD approach, locally around vaccines. For VDPV found only from appropriate messaging is important, so that families environmental sources, it is critical to explain that understand the process and why children may be low immunity is the root cause. vaccinated more than one time in short intervals.

v See “Communication for development guidelines for responding to polio events and outbreaks, post switch”. 2016. Geneva: Global Polio Eradication Initiative (http://polioeradication.org/wp-content/uploads/2016/12/C4DGuidelines_OutbreakPostSwitch_Nov2016_EN.pdf, accessed 8 November 2018).

40 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Protracted outbreak response. Where an communications interventions address the different outbreak is ongoing for more than four months needs, challenges, preferences and perceptions of (120 days), there may be one or more underlying everyone in the community. This review should be communication barriers. As the target audience may done before initiating the response and to guide the include acceptors, vulnerable acceptors, transient development of C4D interventions. groups or even rejecters, conducting a root cause analysis is effective to identify such barriers, After each campaign, IM/LQAS data and or other whether social, or related to access or quality of sources should be analysed in a timely way, the service. Reasons for missed children should be especially regarding the core indicators for C4D, well investigated and analysed to adjust strategies in order to amend communication strategies as for issues such as fatigue of repeated campaigns, or required. Core indicators include: overall percentage mistrust in vaccine or frontline workers. of missed children; percentage of missed children for different reasons (grouped into social, operational In a protracted outbreak, the barriers to acceptance and absences); percentage of refusals; percentage of are specific to each community, culture and region, refusals by reason; percentage of absence by reason; and may be unique and complex. It is important percentage of parents aware of the campaign prior to monitor systematically and understand patterns to vaccinator’s visit; and percentage reached through of reported reasons for missed children before different communication channels. This data must designing communication solutions. The objective is be sex-disaggregated and analysed accordingly. to maintain or increase the percentage of awareness to 90% or more and keep total refusals below 2%. At the end of the outbreak, it is important to assess community acceptance of, and commitment to, Maintaining gains and strengthening routine vaccination, for example, through small-scale immunization. Regardless of how the outbreak surveys or secondary data analysis, and to document evolves, the focus of C4D strategies should shift the outcome of C4D activities. towards supporting routine immunization as soon as possible, and also as the outbreak draws to a close. Outbreak response plans should indicate how Communication strategies routine immunization services will be promoted, Deploying a variety of strategies ensures that especially for low coverage areas. The outbreak communities and decision-makers at local, national, coordination should also develop preparedness and regional levels are engaged in promoting plans to mitigate the risk of future outbreaks. vaccination. The C4D interventions must always The final outbreak response assessment (OBRA) precede the conduct of campaigns to achieve the reviews country improvement plans for routine desired awareness and acceptance of vaccination. immunization and longer-term preparedness. Immediately creating or reinvigorating a national Achievements and lessons learned from social communication or social mobilization committee mobilization, advocacy and media and partnership is critical. The role of the committee is to plan, activities at the national, provincial, and district coordinate and ensure the successful implementation levels should be documented. of media and C4D interventions.

In many contexts, political advocacy is urgent to Data gathering to guide C4D garner the attention needed to support response activities efforts and strengthen public trust in vaccination. At the beginning of an outbreak, it is important At the beginning of the outbreak, media advocacy to review existing data sources for knowledge, is also critical to ensure that information is clear attitudes, practices and behaviour, or if not and managed. The Ministry of Health and WHO, available, to conduct a rapid social assessment of generally the first to announce an outbreak, should norms that may affect vaccination. Gender issues take the lead in this area. As part of the C4D/ should be integrated into data analysis to ensure communication strategy it is recommended to that gender roles and norms are considered, and

RESPONDING TO A POLIOVIRUS 41 EVENT OR OUTBREAK Box 4. Details of C4D and communication activities, including social mapping, training of social mobilizers, engagement with influencers, tracked refusals, etc. should all be included as part of the operational micro plans. establish immediately which agency is leading the Reaching special populations and media response. This leadership role will depend conflict-affected areas on capacity in each country, noting that UNICEF usually leads C4D and supports the media response. Special populations that are hard-to-reach or in conflict areas can be particularly vulnerable to polio Mass and social media play a critical role for outbreaks. The design of strategic C4D interventions reaching a large audience very quickly, especially and messages for these populations should always where interpersonal communication networks are be based on social profiling of polio-confirmed and less strong. In conflict areas, radios are an excellent zero-dose non-polio AFP cases or contact cases, channelling tool. as well as any other available social research for those groups. Engagement with religious and community leaders, health providers, parliamentarians, women’s and Community mobilizers should be selected from youth groups, or other influencers in the social target communities and efforts should be made to network is an important strategy to build strong include women. To build community trust, (s)he public consensus about the urgency of the outbreak should be trained on key messages and be part of and the need to take collectively the decision the vaccination team. to vaccinate. Community influencers/groups should be consulted Training of frontline workers and community and engaged in the planning phase of the campaign mobilizers is critical for high-quality response, with continuation through to the end of the outbreak. especially when the C4D strategy relies on These influencers can be a clan leader, mayor, interpersonal communication. Global training grandmother, school teacher, or a community elder. standards are available for training of vaccinators It would be important to sensitize communities to and other volunteers.w AFP and encourage reporting, including through community networks if applicable.

Geographic, security or demographic challenges could limit access. The use of non-traditional means such as mobile texting, awareness around water points, days when a population moves from one place to the other, printing messages about polio on food bags, or inserting messages in bread packages and other innovations, may augment standard communication strategies.

w See Polio training manual for health worker supervisors. Geneva: Global Polio Eradication Initiative (https://poliok.it/library/Polio%20Training%20 Manual%20For%20Health%20Worker%20Supervisors, accessed 8 November 2018).

42 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK 10 GPEI support

National authorities have the ultimate ownership – surveillance enhancement and accountability for a robust and comprehensive – security and access response to poliovirus outbreaks and the • finance and logistics, including coordinated maintenance of leadership throughout. The GPEI resource mobilization partners support key functions for an outbreak • outbreak response assessment. response including: • outbreak preparedness Table 7 offers a summary of the nature of support • risk assessment and event/outbreak response that GPEI is expected to provide, according to planning the grade of the outbreak as assigned by WHO or • advocacy and coordination amended for GPEI surge support. Each outbreak • technical and human resources, including: is unique, and so are the support needs. Those – information management responsible for outbreak coordination nationally, – communication, social mobilization and regionally and globally, will need to reassess support behaviour change needs on a continuing basis to ensure effective and – vaccination activities timely response.

Table 7. Outbreak response scale-up and support according to grade

Type of Grade 1 Grade 2 Grade 3 Support Response National coordinator GPEI-nominated coordinator GPEI-nominated coordinator and leadership high-level advocacy as needed Technical Polio expert mission from Deployment of a Deployment of a multidisciplinary liaison the GPEI partners to support multidisciplinary rapid response rapid response team outbreak response plan team development Surge Stop Transmission of Polio • Deployment of surge support • Deployment of surge support (STOP) programme support team:1 multidisciplinary team:1 multidisciplinary if needed consultant team for minimum consultant team for minimum six six-month deployment -month deployment • STOP support • STOP support Financial Standard financing ‘No-regrets’ financing policy ‘No-regrets’ financing policy for outbreak response (an advance of up to $500 000) Financial support for security immunization activities prior to completion of response measures, if required (an advance of up to budget US$500 000)2 Security and Coordination with United Coordination with United Deployment of field security officer(s) access Nations and humanitarian Nations and humanitarian where necessary agencies in the field agencies in the field Coordination with United Nations and humanitarian agencies in the field

1 Composition of team and number of experts deployed for rapid response and surge support teams will be scaled up to meet the needs of the country. 2 Standard financing is subject to re-payment conditions, as determined on a case-by-case basis.

RESPONDING TO A POLIOVIRUS 43 EVENT OR OUTBREAK Coordination work plan and budget shared with all levels involved will aid in mobilizing funds from donors to secure Coordination mechanisms for polio are triggered by financing for response activities. a laboratory notification (Day 0) of a new outbreak or high-risk event. The country, region and global WHO headquarters will provide specific guidance levels will coordinate to support the investigation, and timelines on outbreak budgeting. rapid risk assessment and determination of next steps. “No-regrets” financing policy The OPRTT will lead outbreak coordination with The “no-regrets” financing policy (an advance of national authorities, WHO and UNICEF regional up to $500 000) helps ensure a timely, barrier-free offices, and all GPEI partners. The OPRTT will release of funds to countries to support outbreak conduct a coordination call within 48 to 72 hours response, even if it is later realized that a smaller with partners to address the needs of the country, contribution may have sufficed. This policy affirms monitor the immediate provision of no-regrets that it is better to over-resource critical functions funding, and plan the required resources and initial than to risk failure by delays in resources. The response support interventions. The OPRTT will release of funds by GPEI partners may pre-date include all necessary skill sets to coordinate outbreak outbreak grading by WHO, based on the initial response, including a resource mobilization focal risk assessment and discussion between national, point. Regular updates will be provided from regional and global levels. Whereas funds will OPRTT to the GPEI Eradication and Outbreak usually be released by WHO, either UNICEF or Management Group. another GPEI partner may on occasion provide the funding. For grade 2 and 3 outbreaks (and high-risk events), WHO and UNICEF regional offices, in consultation with OPRTT, will nominate an outbreak coordinator Human resource surge for deployment to the country level within 14 days The objectives of GPEI surge support are to: of Day 0. The GPEI outbreak coordinator will be i) rapidly activate deployment of skilled deployed as additional support for in-country professionals, especially for grade 2 and grade authorities, supplementary to existing senior 3 outbreaks, to support the national response GPEI staff, to ensure comprehensive and timely team for key outbreak response functions; and coordination and outbreak management at national ii) ensure smooth transition to longer-term staffing. and subnational levels. It is important to ensure the balanced recruitment of women and men into technical and operational Budgets and financing roles at all levels. The earliest activation is deployment within 72 Coordinated approach hours of laboratory result notification (Day 0) The goal of outbreak response financing is to ensure through a partner-wide interregional mechanism for that cash flow challenges do not interfere with the deploying staff and engaging qualified consultants. roll-out of response activities, based on a “budget– mobilize–finance–replenish” model. National The OPRTT coordinates surge support and technical authorities should rapidly prepare a comprehensive assistance in the following areas: budget, in collaboration with WHO, UNICEF • Identifying key roles, according to outbreak grade and other partners. The budget should include a and assessed needs of the country. Expertise comprehensive estimate of costs for all activities offered includes both technical (communication, (i.e. coordination, vaccination, surveillance, immunization, surveillance, data management), communication and social mobilization) and and operational (coordination, finance, human enabling functions (i.e. laboratory operations, resources) skill sets. training and transport). A joint comprehensive

44 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK • Team composition scaled according to need, GPEI performance standards for example, outbreak coordinator, operations manager, communications officer, and technical The GPEI partners will undertake a range of activities experts for immunization and surveillance. to support a country-led response. Outbreak • Personnel with specialized expertise may also response performance standards describe the be available to provide support to innovative expected outputs from each level of GPEI partners strategies to improve the quality of response, such in key outbreak response functions. The actions as for GIS mapping of the outbreak zone. and deliverables expected of countries and GPEI • The Rapid Response Team involves deployment partners by specific timeline (within hours, days and from respective GPEI agencies, including weeks of virus sequencing report) are outlined in regional offices. Recruitment for active support Annex 2). may extend beyond outbreak teams within These performance standards apply to polio each agency. The period of deployment is from outbreaks of all grades. The time frame for the outbreak notification until the rapid response expected response is counted forward from the date SIA, where indicated. of the initial laboratory sequencing results. These • The Surge Support Team is an interagency standards are not exhaustive and may be modified on-call roster for longer-term deployment as required to fit the context specific to the country using a central platform for ease of visibility and the outbreak. and reporting. The Surge Support Team should be in place within three weeks of outbreak The OPRTT will provide support to coordinate and confirmation. The expected period of deployment monitor the outbreak response. is from the rapid response SIA until the end of the outbreak. Response teams will aim for at least one week of overlap between the work of the Rapid Response Team and that of the Surge Support Team to ensure complete and detailed handover. • Identifying needs and advocating for specialized support and innovation when warranted by context (e.g. GIS-informed microplanning, detailed enumeration, administration, and finance).

RESPONDING TO A POLIOVIRUS 45 EVENT OR OUTBREAK Monitoring and 11 evaluation of response

Quality assurance for outbreak response is critical Table 8 outlines suggested, but not comprehensive, and should include both quantitative and qualitative approaches and indicators for monitoring. Electronic methods for all core aspects of response. Countries data capture using mobile-enabled devices and real- are encouraged to develop tools and indicators time secure data upload is recommended wherever tailored to best monitor all stages and components feasible to support timely and comprehensive of outbreak investigation and response See GPEI reporting for all response activities (surveillance, library for tools and guidance documents. x vaccination, social indicators). The use of electronic data capture methods requires effective training, data cleaning and analysis, and continual quality checks.

Table 8. Assessing quality of response: factors to consider before, during and after implementation

Surveillance Vaccination Communication and social mobilization Planning and preparation • Rapid review of available • Preparedness dashboard • Evidence of engagement with surveillance data indicators >90% community, women’s groups and • Increase ES sampling • Evidence of training for all religious leaders frequency to every two personnel • Engagement of national government weeks • Accurate bottom-up microplans with active support for response • Initiate new ES if with detailed mapping, • Targeted strategies detailed and appropriate complemented by innovations updated for special populations • Validate AFP cases and ES such as GIS imagery and cross- • In-depth social investigation of case(s) sewage sample collection validation where feasible and/or community to identify special populations or under-vaccinated children Implementation • AFP annualized rate • Intra-campaign independent • Targeted strategies used to optimize >3 cases/100 000 children monitoring >90% coverage response activities in special under 15 years of age • Spot checks and surveys >90% populations in outbreak zone and coverage (e.g. at markets, • Evidence of overall increased immediate risk area transit hubs) community sensitization to AFP and • Impact of surveillance • Use of strategies to ensure importance of vaccination enhancement (e.g. source that borders are covered (e.g. • Active support from community and number of AFP cases “handshake” hand-off between including women’s groups and religious reported, active search) teams) leaders active during vaccination • ES process and campaigns 1 performance indicators • No block vaccination refusals

x See GPEI tools, protocols and guidelines (website). Geneva: Global Polio Eradication Initiative (http://polioeradication.org/tools-and-library/resources-for- polio-eradicators/gpei-tools-protocols-and-guidelines/, accessed 8 November 2018).

46 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Surveillance Vaccination Communication and social mobilization Post-campaign follow-up • AFP surveillance >3/100 • Post-campaign independent • Evidence that campaign awareness 000 for at least 12 months monitoring >90% coverage; and was>90% of all households (IM and/or after last poliovirus >80% LQAS lots passed at 90% LQAS) detection threshold • Special populations >90% coverage • Specific analysis of AFP • No evidence of persistently • Analysis of disaggregated data for rate for all high-risk missed children or missed high-risk populations and gender for populations geographic areas missed children or refusals, to guide • Evidence of impact of • Robust and timely reporting, interventions surveillance in hard-to- using innovations such as reach, inaccessible, and mobile-data collection and/or high-risk populations global positioning system (GPS) coordinates for coverage where feasible

1 For detailed guidance see Global Polio Surveillance Action Plan and Polio Environmental Surveillance Enhancement Following Detection of Vaccine-Related Type-2 Poliovirus in GPEI library (http://polioeradication.org/tools-and-library/).

Monitoring quality of SIAs be implemented according to protocol. The goal of intra-campaign monitoring is to ensure corrective The primary indicator for the rapid response SIA action in a timely manner (e.g. the same day or the is the time in days from outbreak notification (Day next day, including re-visit strategies) to improve 0) to the first day of vaccination (Target <14 days). implementation performance. Post-campaign Campaign monitoring may be carried out if capacity monitoring allows in-depth and rigorous analysis allows but should not detract resources from high- for areas missed or not meeting coverage targets, quality microplanning for large-scale SIA1 and SIA2. and an examination of the reasons for missed or SIA 1 and SIA 2 must be fully monitored, and unvaccinated children. results communicated to GPEI partners within 14 Clustered LQAS surveys undertaken with sampling days of each campaign. The purpose of monitoring proportional to population size are recommended is to identify all areas or sub-populations with <90% for all areas covered by outbreak response. For coverage or persistently missed children so that results to be valid, care must be taken to plan and corrective action may be taken. Under-performing implement according to protocol. Specific guidance areas must be comprehensively discussed to is available.y determine special strategies, additional effort (e.g. extending the campaign, additional communications Spot checks, convenience surveys and verbal and/or vaccination teams, or a mop-up round reports by monitors, supervisors, and independent with an adjusted communications strategy), and campaign observers (e.g. international GPEI resources needed. personnel or third-party agency personnel) are a very useful adjunct for SIA monitoring, and should Strategies required to monitor campaigns for all SIAs be welcomed and used liberally to confirm or (SIA1, SIA2), all mop-up activities, and additional question coverage reporting. large-scale SIAs – include, at a minimum, IM and clustered-LQAS. Selection and training of monitors is important. Clear terms of reference outlining independence Intra- and post-campaign monitoring. Intra of the monitors from immunization activities are and post-campaign monitoring employ survey helpful for all monitors. Ideally, monitors should be methods with purposeful sampling in areas where recruited and trained for each SIA round. Deploying coverage is expected to be insufficient and should the same personnel for successive campaigns is

y See “Assessing vaccination coverage levels using clustered lot quality assurance sampling: field manual”. 2012. Geneva, Global Polio Eradication Manual (http://polioeradication.org/wp-content/uploads/2016/09/Assessing-Vaccination-Coverage-Levels-Using-Clustered-LQAS_Apr2012_EN.pdf, accessed 8 November 2018).

RESPONDING TO A POLIOVIRUS 47 EVENT OR OUTBREAK discouraged. Sources for recruitment of monitors and to determine what is needed to address gaps. include universities and colleges (e.g. nursing or Polio OBRAs should be timely, effective, practical medical students), community NGOs or service and independent. agencies (e.g. health workers not directly involved in the response) and should be selected to fit the The first OBRAs is conducted 3 – 4 months local context. after virus notification, a follow up program desk review will be conducted 6–9 months Timeliness of reporting monitoring results is from last detected isolate, or as appropriate to important to ensure accountability, rapid issue the circumstances. Extended outbreaks may identification, and course correction where warrant intermediate OBRAs or desk-reviews. warranted. Monitoring results must be communicated to GPEI partners at national, regional and global An external team of experts will assess the levels within 14 days of campaign completion. quality of response, the evidence of poliovirus transmission and the quality of surveillance. Monitoring surveillance Specifically, the objectives are to: enhancement 1. assess and strengthen efforts to increase Countries should monitor weekly surveillance population immunity; indicators and reporting from all subnational 2. assess progress towards interrupting reporting units with emphasis on high-risk sub- poliovirus transmission; populations and the outcome and impact of all enhancements. 3. assess and strengthen surveillance sensitivity. In addition to routine AFP surveillance indicators The OPRTT and WHO regional office will facilitate with detail to subnational reporting level, regular organization of the OBRAs and follow up program updates on process indicators should be provided, desk reviews in coordination with country teams. including timeliness of investigation, sample For any response with mOPV2, the OBRA team will collection, and receipt at laboratory. recommend management options for the vaccine Reporting should be adequate to allow authorities remaining after all campaigns are completed. For to identify issues early, generate appropriate high-risk events for which vaccination was carried solutions to improve performance, and bolster out, an event response assessment or external desk confidence that the performance is good enough review may also be undertaken. to detect ongoing virus transmission. For example, The OBRA team leader will conduct a debriefing findings from retrospective and ad hoc active case before departing and submit a report to the country searches in community and health facilities should team, OPRTT chair, WHO regional office, and the be comprehensively summarized and reported in a Director of the WHO polio programme. timely manner. The WHO regional office will confirm the end of the The laboratory should also routinely summarize any outbreak based on the response assessment report capacity challenges they face and proposed solutions. and recommendations. The country must provide a post-OBRA action plan Outbreak response assessments within one month of the end of the OBRA. (OBRAs) Detailed guidance, tools and materials for outbreak The purpose of OBRAs is to assess whether response assessments and vaccine management are vaccination and surveillance response is robust available.z enough to detect and stop poliovirus transmission

z See “Polio Outbreak Response Assessment (OBRA): Aide Mémoire”. 2018 (http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/ gpei-tools-protocols-and-guidelines/).

48 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Is the outbreak over? The criteria to determine if a poliovirus outbreak has ended are outlined below in table 9.

Table 9. Criteria to determine if a poliovirus outbreak is over

Criteria to determine if a poliovirus outbreak is over 1 No poliovirus of the outbreak serotype detected from any source (AFP, contact, environmental) for at least six months since virus last detected. AND 2 Surveillance criteria over previous 12 months met in outbreak and high-risk areas, and other areas at risk, including cross-border outbreaks1: i) NPAFP ≥3 per 100 000 population <15 years of age (or national objective, whichever is higher). ii) ≥80% stool adequacy of all AFP case stool collected. AND 3 Convincing evidence that areas at high risk or with conflict, displacement, difficult to access and small populations, have been identified and planned for, and that adapted strategies2 have been successfully implemented to: i) interrupt transmission of poliovirus; ii) detect any ongoing poliovirus transmission. After comprehensive review of indicators, data quality and qualitative information in the local context, the OBRA team has the responsibility to give the best possible opinion as to whether: i) an outbreak appears to be over, even if not all criteria are strictly met; or ii) an outbreak cannot be considered over, even in the absence of detectable virus isolation.

1 Criteria to be met at first administrative level, or second administrative level for populous countries (e.g. India, Nigeria, Pakistan), and other high-risk areas, as determined by the OBRA team. 2 Strategies include: innovative vaccination outreach activities, active case search, community surveillance, estimate of population, as yet unreached by vaccination, by surveillance

The OBRAs should continue until the end of • Repeat program desk reviews after 3–4 months,or outbreak criteria are met. as appropriate . If the ‘end of outbreak’ criteria are not met in a When criteria are met and/or the OBRA team is country or zone, the OBRA team will recommend satisfiedthat outbreak response has been sufficient, the next steps: in following the decision tree below (Figure 7), the • At 6 months with no poliovirus detected, OBRA team recommends that the outbreak can strengthen internal and external support for be closed. response and continue OBRAs and/or external desk reviews as appropriate. The WHO regional office considers the OBRA findings in consultation with the OPRTT, shares the • At 9 to 12 months without virus detected, put in report with the national and regional certification place an additional 3- month emergency plan for: commissions, and may confirm the outbreak a) surveillance, e.g. intense active case search in is over and can be ‘closed’. The country is outbreak area or other enhancements informed accordingly.

b) supplemental immunization, e.g. innovative Figure 7 illustrates a decision tree for determining strategies to reach every child in mobile or if an outbreak has ended. high-risk populations c) routine immunization, e.g. proven strategies to reach every district (RED approach);

RESPONDING TO A POLIOVIRUS 49 EVENT OR OUTBREAK Figure 7. Outbreak response assessment decision tree

Poliovirus outbreak

1st OBRA 3-4months after virus notiﬁ cation No poliovirus detected from any source for at least 6 months

Program desk review 6-9 months without poliovirus detection Good evidence of: Insufﬁ cient evidence of: • high-quality effective immunization response • high-quality immunization • sensitive AFP surveillance • sensitive AFP surveillance

Outbreak Outbreak may not likely ended have ended Response continues

Program desk reviews continues at 3-month intervals or as appropriate • three-month additional emergency surveillance action plan implemented, and 12 months -- plus one month to complete laboratory testing and report -- from time of last poliovirus isolate, and • test results available for all samples collected.

Outbreak likely ended

International Health Regulations 12 months of the last case have also tested negative, whichever is the longer. Polio was declared a public health emergency of international concern on the 5th of May • Environmental isolation of WPV1 or cVDPV 2014, and according to the Temporary (no poliovirus case): 12 months after collection Recommendations issued by the WHO Director of the most recent positive environmental General, the criteria to assess countries as no sample PLUS one month to account for the longer infected by WPV1 or cVDPV are as below. laboratory testing and reporting period. Every three months, the committee meets • Poliovirus Case: 12 months after the onset to review the emergency status and to date of the most recent case PLUS one month determine to which countries the Temporary to account for case detection, investigation, Recommendations should apply. However, laboratory testing and reporting period OR if a country is considered no-longer infected when all reported AFP cases with onset within according to the Temporary Recommendations 12 months of last case have been tested for this does not always mean the outbreak is polio and excluded for WPV1 or cVDPV, closed, as the response may need to continue. and environmental samples collected within

50 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Documenting lessons learned There is great value for countries to review the Typically, best practice in emergency response includes performance of the outbreak or event response a formal after-action review. The lessons learned and document lessons learned. The outbreak are useful in improving emergency preparedness documentation should, among other things, include: planning and can inform response to future events a) a detailed outbreak investigation and risk or outbreaks. assessment Outbreak documentation should also outline b) descriptive epidemiology (including index lessons learned and best practices highlighted by case investigation) the OBRAs as strategic to successful interruption of c) surveillance response to monitor the evolution polio outbreaks. Several relevant documents on best up to the end practice have recently been publishedaa. Support is d) immunization response outlining the key available for countries to document lessons learned milestones for quality assurance and innovations from polio eradication. (micro-planning, training, preparedness monitoring, logistics management, community engagement and monitoring/supervision) e) coordination of the outbreak response, including timing and effectiveness of surge of efforts.

aa See Capturing and sharing lessons learned [website] Geneva: Global Polio Eradication Initiative (http://polioeradication.org/polio-today/preparing-for-a- polio-free-world/transition-planning/lessons-learned-from-polio-eradication/, accessed 8 November).

RESPONDING TO A POLIOVIRUS 51 EVENT OR OUTBREAK Bibliography

For additional information, users of this document are requested to consult the following:

AGORA. UNICEF’s Global Hub for Learning and Development (https://agora.unicef.org/index.php, accessed on 4 December 2018). Assessing immunization coverage with clustered lot quality assurance sampling (clustered-LQAS). Field Manual. Geneva: Global Polio Eradication Initiative; 2012 (http://polioeradication.org/wp-content/uploads/2016/09/Assessing- Vaccination-Coverage-Levels-Using-Clustered-LQAS_Apr2012_EN.pdf, accessed 8 November 2018).

Best Practices for Monitoring the Quality of Polio Eradication Campaign Performance. GPEI guidelines. Geneva: Global Polio Eradication Initiative; 2018 (http://polioeradication.org/wp-content/uploads/2018/08/best-practices-20180810-03.pdf, accessed 8 November 2018).

Best practices for planning a vaccination campaign for an entire population: supplement to Best practices in microplanning for polio eradication. Geneva: World Health Organization; 2018 (WHO/ POLIO/18.04). License: CC BY-NC-SA 3.0 IGO. (http:// polioeradication.org/wp-content/uploads/2018/08/best-practices-20180810-01.pdf, accessed 28 November 2018).

Best practices in microplanning for polio eradication. GPEI guidelines. Geneva: Global Polio Eradication Initiative; 2018 (http:// polioeradication.org/wp-content/uploads/2018/08/best-practices-20180810-03.pdf, accessed 8 November 2018).

15th Meeting of Strategic Advisory Group of Experts (SAGE) Polio Working Group, April 2018 – Conclusions and recommendations, Note for the Record. Geneva: World Health Organization; 2018 (http://www.who.int/immunization/sage/ meetings/2018/april/2_WHO_Polio_SAGE_Apr2018.pdf?ua=1, accessed 8 November 2018).

Guidance note on cold chain logistics and vaccine management during polio supplementary immunization activities. GPEI guidelines. New York: UNICEF; 2017 (http://polioeradication.org/wp-content/uploads/2017/10/Cold-chain-logistics-and- vaccine-management-during-SIA_May2017_EN.pdf, accessed 8 November 2018)

Global guidelines. Independent monitoring of polio supplementary immunization activities. Geneva: Global Polio Eradication Initiative; 2016 (http://polioeradication.org/wp-content/uploads/2016/08/IndependentMonitoringGuidelines_20101124.pdf, accessed 8 November 2018).

Global Polio Laboratory Network (GPLN) [website]. Geneva: Global Polio Eradication Initiative (http://polioeradication.org/polio- today/polio-now/surveillance-indicators/the-global-polio-laboratory-network-gpln/, accessed 4 December 2018).

GPEI Polio outbreak response assessment (OBRA): Aide-Mémoire. (http://polioeradication.org/tools-and-library/ resources-for-polio-eradicators/gpei-tools-protocols-and-guidelines/).

International Health Regulations (2005), 2nd Edition. Geneva: World Health Organization; 2008 (http://www.who.int/ihr/ publications/9789241596664/en , accessed 8 November 2018).

Polio Environmental Surveillance Enhancement Following Detection of Vaccine-Related Type-2 Poliovirus. 2018. Geneva: Global Polio Eradication Initiative (http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/gpei-tools- protocols-and-guidelines/, accessed on 4 December 2018),

52 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Polio eradication and endgame strategic plan 2013–2018 [website]. Geneva: Global Polio Eradication Initiative; 2013 (http:// www.polioeradication.org/resourcelibrary/strategyandwork.aspx, accessed 8 November 2018).

Polio vaccines: WHO position paper – March 2016. Weekly Epidemiological Record. 2016; 91(12):145–168 (http://www.who. int/wer/2016/wer9112.pdf?ua=1), accessed 8 November 2018).

Poliomyelitis: intensification of the global eradication initiative. Report A67/38. In: Sixty-seventh World Health Assembly. Geneva: World Health Organization, 2014 (http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_38-en.pdf, accessed 8 November 2018).

Public Health Management of Facility-Related Exposure to Live Polioviruses: Interim guidance in managing exposed persons for countries hosting facilities that maintain live polioviruses, GPEI website library (http://polioeradication.org/tools-and-library/ resources-for-polio-eradicators/gpei-tools-protocols-and-guidelines/, accessed on 4 December 2018).

Reaching Every District (RED), 2017 revision. Brazzaville: World Health Organization. 2017 (http://apps.who.int/iris/bitstream/ handle/10665/260112/9789290233954-eng.pdf?sequence=1&isAllowed=y, accessed 8 November 2018).

Reporting and classification of vaccine-derived polioviruses. GPEI guidelines. Geneva: Global Polio Eradication Initiative; 2016 (http://polioeradication.org/wp-content/uploads/2016/09/Reporting-and-Classification-of-VDPVs_Aug2016_EN.pdf, accessed 8 November 2018).

Rhizome by GPEI; Tools and guidance to help you design data-driven communication strategies that help vaccinate every child (https://poliok.it/c4d, accessed on 4 December 2018).

Stop Transmission of Polio (STOP) Program [website]. Atlanta: United States Centers for Disease Control (http://www.cdc.gov/ globalhealth/immunization/stop/index.htm, accessed 8 November 2018).

Surveillance Indicators [website]. Geneva: Global Polio Eradication Initiative (http://www.polioeradication.org/ Dataandmonitoring/Surveillance.aspx, accessed 4 December 2018).

Technical guidance: mOPV2 vaccine management, monitoring, removal and validation. Oct 2016. (http://polioeradication.org/ wp-content/uploads/2016/11/Technical-guidance-mOPV2-management-monitoring-removal-and-validation_Oct2016_EN.pdf, accessed 30 October 2018).

Use of fractional-dose inactivated polio vaccine (fIPV) in supplementary-immunization activities (SIAs). GPEI Aide Mémoire, 2017 (http://polioeradication.org/wp-content/uploads/2017/11/polio-fipv-in-sias-aide-memoire-01092017-en.pdf, accessed 8 November 2018).

Use of AFP contact sampling and targeted healthy children stool sampling. GPEI Job Aid. 2019 (http://polioeradication.org/ wp-content/uploads/2016/07/AFP-contact-sampling-and-targeted-healthy-children-stool-sampling-20190919.pdf, accessed 20th January 2020).

Vaccine-associated paralytic polio (VAPP) and vaccine-derived poliovirus (VDPV). GPEI fact sheet. Geneva: World Health Organization; 2015 (http://www.who.int/immunization/diseases/poliomyelitis/endgame_objective2/oral_polio_vaccine/ VAPPandcVDPVFactSheet-Feb2015.pdf, accessed 8 November 2018).

World Health Assembly. Resolution WHA68 on Poliomyelitis. In: Sixty-eighth World Health Assembly. Geneva: World Health Organization, 26 May 2015. (http://apps.who.int/gb/ebwha/pdf_files/WHA68-REC1/A68_R1_REC1-en.pdf#page=1, pg. 10. accessed 8 November 2018).

WHO Global Action Plan to minimize poliovirus facility-associated risk after type-specific eradication of wild polioviruses and sequential cessation of oral polio vaccine use. Geneva: World Health Organization; 2015 (http://apps.who.int/iris/ handle/10665/208872, accessed 8 November 2018).

RESPONDING TO A POLIOVIRUS 53 EVENT OR OUTBREAK Annexes

Annex 1. Risk assessment overview: Summary of elements for systematic risk assessment of a new VDPV, WPV or SL2 isolation.

Annex 2. Timeline and responsibility for outbreak response activities from Day 0 to outbreak closure

54 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Annex 1. Risk assessment overview: Summary of elements for systematic risk assessment of a new VDPV, WPV or SL2 isolation

Risk Category High risk Low risk Remarks Virology cVDPV Automatically defined as high-risk situation Virologic factors • Genetic deviation from parent Sabin (nucleotide Substantial Not Seek expert changes) Substantial virologist • Relatedness, if any, to past isolations Related assessment • Virologist characterization / interpretation Yes Not related • Co-circulation with WPV Yes No • Detection of other (un-related) VDPVs in region Yes No No Human source • Co-isolation with other Sabin or enterovirus Yes • Evidence of primary immunodeficiency No No Yes Environmental source • Number / density of virus in samples High • Mix of poliovirus, Sabin virus, and other enteric Yes Medium/low virus in sample No Context Case Characteristics Review and discussion by • Member of known “high risk”/underserved Yes No technical experts, population (slum, minority, refugee, mobile, between country, internally displaced, etc.) region and global • 0 dose or “under”-vaccinated Yes No levels • Aged above 5 years Yes No Coverage data ”Population Immunity” for type 2 • RI coverage (IPV if available-otherwise diptheria- Poor Good/high polioviruses, should tetanus-pertussis (DPT3) in infected Admin 1 level factor time since • Quality of prior SIAs (>5% missed children by IM Poor Fair/good switch and use of data) IPV to estimate type 2 naïve population Surveillance quality

• Surveillance gaps (e.g. sub-standard AFP Evident Fair/good indicators, infrequent or absent ES, orphan virus) in infected Admin 1 level • Other recent poliovirus detection Yes No

RESPONDING TO A POLIOVIRUS 55 EVENT OR OUTBREAK 30+

Risk Category High risk Low risk Remarks Admin level 1 context 15–30

• Large, densely populated area Yes No 14

• Known high risk populations (e.g. mobile, refugee, Yes No 13 trade, pilgrimage, displacement) • Insecure and/or inaccessible area affecting Yes No 12 surveillance and/or immunization 11 • Any type of sentinel events suggesting higher risk Yes No

of rapid spread 10

• Evidence of containment breach Yes No 9 • Finding tOPV/mOPV2 in a sweep of the vaccine Yes No

distribution chain 8 • Environmental conditions associated with high Poor water and Fair/good 7 levels of fecal-oral transmission sanitation water and

sanitation 6 International Spread 5 Linkages with International Border Local case investigation / based 4 • Contiguous or direct transport link to int’l border Yes No on available data (especially if other area is known high risk) 3 Review and

• Links between site or person with poliovirus to Yes No discussion by GPEI 2 other countries (e.g. markets, transport routes) technical experts, • Travel history of poliovirus case or household (e.g. Yes No in consultation with 1 refugee, nomadic, pilgrimage, stateless persons) country, regional 0 • History of any other sentinel event shared across Yes No levels sequencing results post Days borders • Prior history of polio transmission patterns and Yes No outbreaks between countries

Population mobility-migration • Common service points between infected area and Yes No neighbouring areas like markets, pilgrim sites, watering points for nomads • Evidence of high levels of migration (from Yes No sequencing data, available cell phone data, prior migration patterns, etc.)

Context of neighboring areas • Evidence of surveillance gaps or other high- Yes No risk factors in neighboring areas susceptible to importation from affected area • Population immunity in neighbouring countries Low Good/high • Conflict Present None Timeline and responsibility for actions in the first month following poliovirus detection poliovirus month following actions in the first for Timeline and responsibility Actions Notification regional office, and WHO at country country health authorities of the affected GPLN informs levels and headquarters office Polio Global relevant informs health authorities, WHO headquarters Country informs (GPEI) partners Initiative Eradication point notifies WHO IHR focal Investigation investigation epidemiological/social initiates Country team Coordination and headquarters, offices mechanisms at regional response event/outbreak Establish GPEI partner coordination for including the OPRTT as soon available and deploy surge response rapid Activate as soon available support and deploy surge Activate plan and response Risk assessment (Advisory GPEI partners to proposal and response risk assessment presents Country team - EOMG) Management Group and Outbreak mOPV2 (AD G) /Eradication for Group mOPV2 (if applicable) for request vaccine submits Country team team country to recommendations (AD G/EOMG) meet and provide GPEI partners (WHE) Headquarters, by WHO Health Emergencies be graded to Outbreak as per the ERF Framework plan and budget response finalize and submit outbreak to Country team management Vaccine (if applicable) stockpile of mOPV2 from authorizes release WHO Director-General (if applicable) country shipped to and syringes mOPV2 vaccine (if applicable) field sent to mOPV2 vaccine activities Response fund initial to office regional/country to $500 000) released funding (up to No regrets activities response a National Public Health Emergency polio outbreak Declare plan and communication a national advocacy and implement Develop activities enhancement surveillance Initiate 0” “Round Implement the country to and funds release budget endorsed response Outbreak SIA 1, 2 and mop-up rounds Implement Annex 2A : Annex

56 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK 30+ 15–30 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 Days post sequencing results sequencing results post Days Timeline and responsibility for actions in the first month following poliovirus detection poliovirus month following actions in the first for Timeline and responsibility Actions Notification regional office, and WHO at country country health authorities of the affected GPLN informs levels and headquarters office Polio Global relevant informs health authorities, WHO headquarters Country informs (GPEI) partners Initiative Eradication point notifies WHO IHR focal Investigation investigation epidemiological/social initiates Country team Coordination and headquarters, offices mechanisms at regional response event/outbreak Establish GPEI partner coordination for including the OPRTT as soon available and deploy surge response rapid Activate as soon available support and deploy surge Activate plan and response Risk assessment (Advisory GPEI partners to proposal and response risk assessment presents Country team - EOMG) Management Group and Outbreak mOPV2 (AD G) /Eradication for Group mOPV2 (if applicable) for request vaccine submits Country team team country to recommendations (AD G/EOMG) meet and provide GPEI partners (WHE) Headquarters, by WHO Health Emergencies be graded to Outbreak as per the ERF Framework plan and budget response finalize and submit outbreak to Country team management Vaccine (if applicable) stockpile of mOPV2 from authorizes release WHO Director-General (if applicable) country shipped to and syringes mOPV2 vaccine (if applicable) field sent to mOPV2 vaccine activities Response fund initial to office regional/country to $500 000) released funding (up to No regrets activities response a National Public Health Emergency polio outbreak Declare plan and communication a national advocacy and implement Develop activities enhancement surveillance Initiate 0” “Round Implement the country to and funds release budget endorsed response Outbreak SIA 1, 2 and mop-up rounds Implement Annex 2A : Annex

RESPONDING TO A POLIOVIRUS 57 EVENT OR OUTBREAK With support from WHO and UNICEF With support from and headquarters office regional GPEI inform to WHO headquarters EOMG, Strategy (OPRTT, partners - SC) Committee to GPEI partners With support from the national health authorities ensure to information the necessary have with country effectively communicate stakeholders. WHO and UNICEF regional offices/ WHO and UNICEF regional required provide rapidly to headquarters documents WHO and UNICEF regional offices and offices WHO and UNICEF regional headquarters Regional/Global Regional/Global Responsibility National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from National health authorities National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from Country Brief Minister of Health, Head of Government/State and of Health, Head Government/State Brief Minister for required officials on the specific steps other relevant the outbreak: stop to response an urgent polio a National Public Health Emergency 1. Declare or advise the of outbreak in case within 72 hours if the virus is an emergency declare need to potential as an outbreak. reclassified center operating a national emergency 2. Establish is structure coordination emergency if an existing (EOC) official by a senior government led in place, not already point and supported focal outbreak as the designated communication, strategic administration, for by staff management and finance. supply logistics, operations, Inform national authorities and other relevant partners. national authorities and other relevant Inform Part B: Determine geographic extent of transmission (i.e of transmission extent geographic B: Determine Part etc.). search sampling, active contact the stop to operations response the required 3.Implement SOPs, response as per the outbreak virus transmission 7). (see Chapter virus type and classification Establish an outbreak management team with management team an outbreak Establish agencies. all relevant from representation Find national polio outbreak preparedness and response and response preparedness Find national polio outbreak in National Certification in Annex be found plan (can report). (NCC) Committee Identify trained or experienced polio outbreak response response polio outbreak or experienced Identify trained in country/region. persons Read any reports or documents of previous outbreak outbreak of previous or documents any reports Read activities. response documents guidance has technical team country Ensure SOPs, (outbreak and response support investigation to etc.). template, risk assessment template, investigation Initiate joint epidemiological and social investigation and social investigation joint epidemiological Initiate guidance): for 4 and template (see Chapter context and local isolate case/ES A: Investigate Part Activities Outbreak Outbreak coordination and advocacy Communication Function Outbreak Outbreak coordination Resources Resources Resources Resources Resources Resources Resources Investigation Timeline and responsibility for outbreak response activities from Day 0 to close of outbreak close 0 to Day activities from response outbreak for Timeline and responsibility Within of 24 hours notification Notification Notification of virus from - laboratory 0 Day Within of 24 hours notification Timeline Annex 2B : Annex

58 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK With support from WHO and UNICEF With support from and headquarters office regional GPEI inform to WHO headquarters EOMG, Strategy (OPRTT, partners - SC) Committee to GPEI partners With support from the national health authorities ensure to information the necessary have with country effectively communicate stakeholders. WHO and UNICEF headquarters GPEI partners and chair calls initiative to OPRTT regional WHO/UNICEF from support With and headquarters office WHO and UNICEF regional offices/ WHO and UNICEF regional required provide to headquarters rapidly documents coordinate to OPRTT regional WHO/UNICEF from support With and headquarters office WHO and UNICEF regional offices/ WHO and UNICEF regional required provide rapidly to headquarters documents WHO and UNICEF regional offices and offices WHO and UNICEF regional headquarters Regional/Global Regional/Global Regional/Global Responsibility Responsibility National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from National health authorities WHO and UNICEF to participate WHO and UNICEF to National health authorities, WHO and UNICEF offices country National health authorities with support from offices WHO and UNICEF country National health authorities WHO and UNICEF country offices to make make to offices WHO and UNICEF country arrangements in-country National health authorities with support from offices WHO and UNICEF country National health authorities, WHO and UNICEF and nominate agree to offices country National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from Country Country Conduct a press briefing/media release briefing/media release Conduct a press Conduct a media landscape analysis Conduct a media landscape media monitoring. Initiate Brief Minister of Health, Head of Government/State and of Health, Head Government/State Brief Minister for required officials on the specific steps other relevant the outbreak: stop to response an urgent polio a National Public Health Emergency 1. Declare or advise the of outbreak in case within 72 hours if the virus is an emergency declare need to potential as an outbreak. reclassified center operating a national emergency 2. Establish is structure coordination emergency if an existing (EOC) official by a senior government led in place, not already point and supported focal outbreak as the designated communication, strategic administration, for by staff management and finance. supply logistics, operations, Inform national authorities and other relevant partners. national authorities and other relevant Inform Part B: Determine geographic extent of transmission (i.e of transmission extent geographic B: Determine Part etc.). search sampling, active contact the stop to operations response the required 3.Implement SOPs, response as per the outbreak virus transmission 7). (see Chapter virus type and classification mechanism at all levels monitoring systematic 4. Ensure progress monitor to and district) (national, regional up actions and follow of planning, implementation activities. response throughout of of the progress reporting and regular 5. Timely the head of government/ activities to response outbreak and GPEI partners. state division if type 2 poliovirus UNICEF supply Alert to: counterparts and government with partners Work • • • Initiate event/outbreak response mechanisms at regional mechanisms at regional response event/outbreak Initiate any available Share levels. and headquarters office risk assessment, (draft team with country information security coverage, historical assessments, surveillance etc.). high-risk groups, assessments, to (OPRTT) Team and Preparedness Response Outbreak WHO, UNICEF between calls conference weekly establish and GPEI partners. of the national HR capacity the on-the-ground Assess WHO, UNICEF and other in-country health system, operations. response implement to partners Request expedited procedures for visas at the port of for procedures expedited Request responders. outbreak any international entry for Activate surge support processes; deploy as soon deploy support processes; surge Activate 21 Target Response; - Rapid 72 hours (Target available. Support). - Surge days for with proposal template risk assessment Initiate and (see template strategy immunization response 7). chapter the for and spokesperson person Identify a media focal outbreak. Establish an outbreak management team with management team an outbreak Establish agencies. all relevant from representation Find national polio outbreak preparedness and response and response preparedness Find national polio outbreak in National Certification in Annex be found plan (can report). (NCC) Committee Identify trained or experienced polio outbreak response response polio outbreak or experienced Identify trained in country/region. persons Read any reports or documents of previous outbreak outbreak of previous or documents any reports Read activities. response documents guidance has technical team country Ensure SOPs, (outbreak and response support investigation to etc.). template, risk assessment template, investigation Initiate joint epidemiological and social investigation and social investigation joint epidemiological Initiate guidance): for 4 and template (see Chapter context and local isolate case/ES A: Investigate Part Activities Activities Outbreak Outbreak coordination and advocacy Communication Communication Outbreak Outbreak coordination Outbreak coordination HR surge support HR surge HR surge support HR surge HR surge support Risk and assessment response Communication Communication Function Function Outbreak Outbreak coordination Resources Resources Resources Resources Resources Resources Resources Investigation Timeline and responsibility for outbreak response activities from Day 0 to close of outbreak close 0 to Day activities from response outbreak for Timeline and responsibility Within of 24 hours notification Within of 24 hours notification Within of 24 hours notification Notification Notification of virus from - laboratory 0 Day Within of 24 hours notification Timeline Timeline Annex 2B : Annex

RESPONDING TO A POLIOVIRUS 59 EVENT OR OUTBREAK

Regional/Global Regional/Global WHO headquarters to coordinate and coordinate to WHO headquarters release Division UNICEF Supply mOPV2 Advisory Group secretariat to review review to secretariat mOPV2 Advisory Group Division UNICEF Supply and send to WHE coordinate, to WHO headquarters with in consultation grade to Headquarters office regional WHO Headquarters to support to WHO Headquarters WHO regional office and headquarters and headquarters office WHO regional support as required security advisors and office WHO/UNICEF regional support with OPRTT Headquarters support to UNICEF Headquarters Responsibility Country UNICEF country office office UNICEF country National Health Authorities point National IHR focal with national offices WHO and UNICEF country health authorities WHO country office WHO country WHO and UNICEF representatives with national in collaboration UNDSS, authorities National Health Authorities with support from offices WHO and UNICEF country National Health Authorities with support from offices WHO and UNICEF country National Health Authorities with support from offices WHO and UNICEF country Release “no regret” funding (up to $500 000) to regional/ $500 000) to funding (up to “no regret” Release activities. fund initial response to office country as per vaccine response shipment of bundled Initiate proposal. response Declare polio a National Public Health Emergency. Declare be WHO; a summary may to Submit IHR notification as a Disease on the WHO website publicly reported (DON). Notification Outbreak grading for call in WHO 3-level and participate Prepare office regional headquarters, by WHE, WHO Polio Response as per the Emergency office, and country Framework. proposal, and response 1) Finalize risk assessment including from information, with all available neighbouring countries OPRTT/ to and proposal risk assessment 2) Present or mOPV2 3 poliovirus) 1 or Type EOMG (Type and feedback for 2 poliovirus) (Type Advisory Group recommendations. forecasts, plan including: vaccine a logistics Complete utilization distribution, warehousing, storage, cold and disposal (see accountability, vaccine monitoring, management guidance. vaccine authorization of for form request Submit mOPV2 vaccine by WHO Director-General. realease vaccine Coordinate with the United Nations Department of Safety Nations Department of Safety with the United Coordinate missions. on field and Security (UNDSS) of the virus in the area the security and access Assess security advisor Request areas. and surrounding isolate assessment. level a field conduct to Inform the United Nations Resident Coordinator and the Coordinator Nations Resident the United Inform Country Team. Humanitarian Activities Finance Logistics IHR notification Grading Function Logistics Logistics planning request Vaccine Risk assessment and response planning Complex Complex emergency settings (if applicable) Outbreak response Within 72 hours of (3 days) notification Timeline

60 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Regional/Global Regional/Global OPRTT to facilitate review and review facilitate to OPRTT GPEI partners from recommendations WHO and UNICEF regional offices to to offices WHO and UNICEF regional support offices/ WHO and UNICEF regional support to headquarters Responsibility Country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country Background and risk for further transmission and risk for Background timing, etc.) of SIAs (scope, strategy Proposed activities enhancement Surveillance and social mobilization communication Advocacy, activities and partnerships Coordination assessment Human resources response and outbreak evaluation Monitoring, (OBRA) assessments Budget Pre-campaign awareness sessions targeting high-risk targeting sessions awareness Pre-campaign populations and hard-to-reach and ensuring communities communication Proactive of the the dangers sensitized to are health workers of the vaccine disease and benefits Engagement of key influencers and key stakeholders stakeholders and key influencers Engagement of key leaders, community religious, (including political, hard-to-reach to access provide to celebrities) communities plan to of a special crisis communication Development vaccination to of resistance in case rumours address following events adverse actions to respond and rapid vaccination. Activities Communicate preliminary plan to all provinces and all provinces plan to preliminary Communicate activities. in response involved districts plan (see response of the outbreak development Initiate guidance). detailed for template • • • • • • • • subnational teams and input from Seek feedback Activate the national emergency operating center (EOC) (EOC) center operating the national emergency Activate out roll to structure coordination emergency or existing immunization response the first for activities required plan. response and subsequent activities in the outbreak and of a national advocacy development Initiate on community plan focusing communication information engagement, social mobilization and general response the outbreak across strategies dissemination Include: guidance.) detailed 9 for period. (See Chapter • • • • Function Function Outbreak Outbreak response Advocacy and Advocacy communication Advocacy and Advocacy communication Timeline Within 72 hours of (3 days) notification Within 72 hours of (3 days) notification

RESPONDING TO A POLIOVIRUS 61 EVENT OR OUTBREAK Regional/Global Regional/Global Regional/Global Regional/Global WHO/UNICEF regional office WHO/UNICEF regional WHO regional offices offices WHO regional GPEI partner review coordinate to OPRTT and budget and feedback WHO regional offices offices WHO regional With support from WHO/UNICEF regional WHO/UNICEF regional With support from and headquarters offices and headquarters office UNICEF regional support to UNICEF regional office and headquarters office UNICEF regional OPRTT to facilitate GPEI partner support facilitate to OPRTT support to GPEI partners and offices WHO/UNICEF regional OPRTT, Headquarters directors WHO/UNICEF regional UNICEF regional office and headquarters and headquarters office UNICEF regional support to and headquarters office UNICEF regional support with OPRTT Responsibility Responsibility Country Country National health authorities National health authorities, with WHO country office National health authorities, with support from offices WHO and UNICEF country facilitate to offices WHO and UNICEF country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country National health authorities and UNICEF office country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country WHO country office office WHO country National health authorities with support from National health authorities with support from UNDSS National health authorities with UNICEF office country WHO and UNICEF country offices with offices WHO and UNICEF country and media donors in-country WHO and UNICEF country offices offices WHO and UNICEF country National health authorities with UNICEF office country Notify and sensitize health care workers at national workers Notify and sensitize health care about notification units and subnational surveillance requirements activities AFP case-finding supplemental Implement in the AFP active sites reporting and reclassify Review network surveillance in outbreak is involved the national laboratory Ensure is strengthened capacity ensure planning to sampling from of environmental frequency Increase and appropriate. feasible where sites, existing already Mapping community leaders, key players, players, key leaders, Mapping community and identify influencers stakeholders point vaccination permanent/transit Planning for areas inaccessible surrounding strategies to strategies vaccination opportunistic Planning for areas. populations in inaccessible reach Activities Activities Develop a preparedness dashboard to assess readiness readiness assess to dashboard a preparedness Develop example, of activities (for tracking Initiate 0”. “Round for guidance). for available dashboards activates enhancement surveillance Initiate guidance.): detailed 8 for (See Chapter • • • • • high-level secure plan to advocacy an external Develop and country the affected from commitment political efforts. advocacy in-country complement the to write to directors WHO and UNICEF regional and of Health highlighting the emergency Minister and representatives the full support of country and support. guidance for organizations Determine human resources surge requirements with requirements surge human resources Determine needs. and country based on grading OPRTT Conduct a follow up media briefing on plans and Conduct a follow the outbreak. to responding for proposals of long-term and list the C4D polio toolkit Share use immediately can office that the country agreements activities. response accelerate to and context of the case the social profiling Complete guide the to tools investigation using special country design of C4D interventions. Provide a briefing to the highest government authorities government the highest a briefing to Provide brief) and other key memo or presidential (e.g. cabinet response a successful needed for partners strategic political/religious/ parliamentarians, ministries, (relevant in the epicenter). partners health and NGO civic leaders, Initiate outbreak response plan activity monitoring to to plan activity monitoring response outbreak Initiate dashboard). (e.g. tracker, implementation track in the stakeholders meeting with key a weekly Establish of the implementation and monitor coordinate to country plan. response outbreak macro of the national operations development Initiate coordination strategy, 0” detailing “Round plan for human resources, logistics, vaccine, structure, and supervision, social mobilization, communication needs, etc. training subsequent SIA 1/SIA 2 and plan for macro Revise additional mop-up round. Finalize outbreak response plan and six-month budget response Finalize outbreak and timing); guidance for and budget SOPs (see template finalize within one week. to team country Initiate partner coordination with other United Nations with other United partner coordination Initiate agencies on the ground. and humanitarian Initiate development of an access plan, including: of an access development Initiate • • • Initiate weekly media briefing on the response plan and media briefing on the response weekly Initiate activities. of immunization and surveillance status Inform broader donor community of poliovirus of poliovirus donor community broader Inform activities, of polio response and status notification including immunization and surveillance. Finalize media protocol kit with key messages, produce produce messages, kit with key Finalize media protocol relevant products and other communication media briefs use. and regional/global local for the outbreak to Initiate the development of a joint WHO/UNICEF situation the development Initiate on weekly GPEI partners update (SITREP) to report planning and response of investigation, the progress guidance). for available activities (template Function Function Function Function Outbreak Outbreak plan response and budget Partner coordination Outbreak response plan operations Outbreak Outbreak plan response and budget Partner Partner coordination Communication Communication Communication Communication Outbreak Outbreak response Surveillance enhancement and Advocacy communication and Advocacy communication Communication Human resources support surge Communication Complex emergency settings (if applicable) Communication Communication C4D, social mobilization and communication Timeline Within of 7 days notification Timeline Within of 14 days notification Within of 7 days notification

62 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Regional/Global Regional/Global WHO/UNICEF regional office WHO/UNICEF regional WHO regional offices offices WHO regional GPEI partner review coordinate to OPRTT and budget and feedback WHO regional offices offices WHO regional With support from WHO/UNICEF regional WHO/UNICEF regional With support from and headquarters offices and headquarters office UNICEF regional support to Responsibility Country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country WHO country office office WHO country National health authorities with support from National health authorities with support from UNDSS National health authorities with UNICEF office country WHO and UNICEF country offices with offices WHO and UNICEF country and media donors in-country WHO and UNICEF country offices offices WHO and UNICEF country National health authorities with UNICEF office country Mapping community leaders, key players, players, key leaders, Mapping community and identify influencers stakeholders point vaccination permanent/transit Planning for areas inaccessible surrounding strategies to strategies vaccination opportunistic Planning for areas. populations in inaccessible reach Activities Initiate outbreak response plan activity monitoring to to plan activity monitoring response outbreak Initiate dashboard). (e.g. tracker, implementation track in the stakeholders meeting with key a weekly Establish of the implementation and monitor coordinate to country plan. response outbreak macro of the national operations development Initiate coordination strategy, 0” detailing “Round plan for human resources, logistics, vaccine, structure, and supervision, social mobilization, communication needs, etc. training subsequent SIA 1/SIA 2 and plan for macro Revise additional mop-up round. Finalize outbreak response plan and six-month budget response Finalize outbreak and timing); guidance for and budget SOPs (see template finalize within one week. to team country Initiate partner coordination with other United Nations with other United partner coordination Initiate agencies on the ground. and humanitarian Initiate development of an access plan, including: of an access development Initiate • • • Initiate weekly media briefing on the response plan and media briefing on the response weekly Initiate activities. of immunization and surveillance status Inform broader donor community of poliovirus of poliovirus donor community broader Inform activities, of polio response and status notification including immunization and surveillance. Finalize media protocol kit with key messages, produce produce messages, kit with key Finalize media protocol relevant products and other communication media briefs use. and regional/global local for the outbreak to Initiate the development of a joint WHO/UNICEF situation the development Initiate on weekly GPEI partners update (SITREP) to report planning and response of investigation, the progress guidance). for available activities (template Function Function Outbreak Outbreak plan response and budget Partner coordination Outbreak response plan operations Outbreak Outbreak plan response and budget Partner Partner coordination Communication Communication Communication Communication Communication Communication Communication Complex emergency settings (if applicable) Timeline Within of 14 days notification Within of 7 days notification

RESPONDING TO A POLIOVIRUS 63 EVENT OR OUTBREAK Regional/Global Regional/Global Regional/Global Regional/Global WHO/UNICEF regional offices offices WHO/UNICEF regional OPRTT to facilitate support from partners partners support from facilitate to OPRTT provide to office WHO/UNICEF regional support technical provide to WHO headquarters support office WHO regional WHO/UNICEF regional office WHO/UNICEF regional UNICEF regional office and headquarters office UNICEF regional UNICEF regional office and headquarters and headquarters office UNICEF regional support provide to OPRTT to facilitate support from GPEI support from facilitate to OPRTT partners to office/headquarters WHO regional support provide OPRTT to facilitate process process facilitate to OPRTT Responsibility Responsibility Country Country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country National health authorities National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with WHO and office UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country WHO and UNICEF country offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country Engage the community leaders and identified leaders Engage the community influencers and influencers players, key through access Negotiate stakeholders point vaccination a permanent/transit Implement areas inaccessible surrounding strategies to strategies vaccination opportunistic Implement areas. populations in inaccessible reach Supervision and post-campaign) (intra- Independent monitoring daily performance, meetings (team review Daily reporting) sampling (LQAS) Lot quality assurance related issues refusals, including vaccine SIA reviews, etc. mistrust, to Activities Activities Within 14 days, implement “Round 0” immunization “Round implement Within 14 days, response. Deploy a field security officer. a field Deploy listed of strategies plan (examples access Implement below): • • • • Implement the advocacy and communication plan to and communication the advocacy Implement at the national and stakeholders engage all relevant activities. response in outbreak subnational levels (SITREP) is that joint WHO/UNICEF situation report Ensure among partners. and circulated generated and positions in infected fill vacant to process Initiate high-risk areas. comprehensive ensure mOPV2 response For and monitoring management of all vials. Detailed and remaining retrieved, of vials deployed, reporting at the end of each immunization activity is for unaccounted management guidance.) (See vaccine required. Develop tools and training for development of micro of micro development for and training tools Develop coordination strategies, detailing 0”, “Round plans for human resources, logistics, vaccine, structure, and supervision, social mobilization, communication microplanning for practice (Best needs, etc. training guidance.) for available subsequent SIA 1/SIA 2 and plans for micro Revise additional mop-up round. Develop tools and training for development of micro of micro development for and training tools Develop structure, coordination strategies, plans detailing supervision, human resources, logistics, vaccine, needs and training social mobilization, communication for is available microplanning for practice (Best etc. guidance.) Establish campaign monitoring for SIAs: for monitoring campaign Establish • • • • • interventions. of communication monitoring Establish Develop SIAs preparedness monitoring dashboards dashboards monitoring SIAs preparedness Develop at national and SIAs readiness assess be used to to subnational levels. one week weeks, two assessments Conduct readiness inform to SIA implementation prior to days and three SIAs quality assurance. support for technical targeted and external of the internal the implementation Track interventions of successful note plans. Taking advocacy OPRTT. further needs to and communicating OPRTT and EOMG to provide endorsement of outbreak of outbreak endorsement provide and EOMG to OPRTT and initiate plan and budget (within 20 days) response funds funds. Within 28 days release mechanisms to in country. be available should Function Function Function Function Vaccine Vaccine management Communication Immunization C4D, social Micro plan Micro development mobilization and communication Complex emergency settings (If applicable) Micro plan Micro development Monitoring Monitoring immunization Monitoring communication Monitoring Monitoring preparedness Monitoring preparedness Monitoring advocacy Finances Within of 14 days notification Timeline Timeline until 14 days of completion immunization activities (75–90 days)

64 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Regional/Global Regional/Global UNICEF regional office and headquarters and headquarters office UNICEF regional support provide to OPRTT to facilitate support from GPEI support from facilitate to OPRTT partners to office/headquarters WHO regional support provide OPRTT to facilitate process process facilitate to OPRTT Responsibility Country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with WHO and office UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country Supervision and post-campaign) (intra- Independent monitoring daily performance, meetings (team review Daily reporting) sampling (LQAS) Lot quality assurance related issues refusals, including vaccine SIA reviews, etc. mistrust, to Activities Develop tools and training for development of micro of micro development for and training tools Develop structure, coordination strategies, plans detailing supervision, human resources, logistics, vaccine, needs and training social mobilization, communication for is available microplanning for practice (Best etc. guidance.) Establish campaign monitoring for SIAs: for monitoring campaign Establish • • • • • interventions. of communication monitoring Establish Develop SIAs preparedness monitoring dashboards dashboards monitoring SIAs preparedness Develop at national and SIAs readiness assess be used to to subnational levels. one week weeks, two assessments Conduct readiness inform to SIA implementation prior to days and three SIAs quality assurance. support for technical targeted and external of the internal the implementation Track interventions of successful note plans. Taking advocacy OPRTT. further needs to and communicating OPRTT and EOMG to provide endorsement of outbreak of outbreak endorsement provide and EOMG to OPRTT and initiate plan and budget (within 20 days) response funds funds. Within 28 days release mechanisms to in country. be available should Function Function Micro plan Micro development Monitoring Monitoring immunization Monitoring communication Monitoring Monitoring preparedness Monitoring preparedness Monitoring advocacy Finances Timeline until 14 days of completion immunization activities (75–90 days)

RESPONDING TO A POLIOVIRUS 65 EVENT OR OUTBREAK Regional/Global Regional/Global UNICEF regional office and headquarters to and headquarters office UNICEF regional support provide OPRTT, WHO/UNICEF regional offices and offices WHO/UNICEF regional OPRTT, headquarters WHO regional office WHO regional GPEI support from facilitate to OPRTT partners OPRTT to provide support provide to OPRTT Responsibility Country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country Triangulation of data including: low performing areas, areas, performing including: low of data Triangulation or other observed children on refusals/missed social data etc. data surveillance social barriers, Conduct additional vaccinator and supervisor training and supervisor training Conduct additional vaccinator skills interpersonal for and regular supervision, monitoring Strengthen meetings during campaign review high-risk missed, reach to special strategies Initiate populations or mobile the quality of SIAs, improve Conduct activities to by GIS supported microplanning including detailed and feasible. appropriate mapping where Activities Conduct trainings of front-line workers (vaccinators, (vaccinators, workers of front-line Conduct trainings skills, on technical and social mobilizers) supervisors SIA 1 and 2 skills for and interpersonal communication areas. targeted management and vaccine capacity cold-chain Assess SIA 1. fill gaps prior to to steps urgent and take capabilities subsequent immunization activities (SIA 1,Implement plan. response as per outbreak SIA 2, mop-up round) the quality of SIAs with each improve Conduct activities to subsequent round: • • • • • Liaise with in-country data managers to identify and to managers data Liaise with in-country issues. and completeness format data resolve Conduct regular donor meetings and advocacy activities. donor meetings and advocacy Conduct regular Ensure in-depth discussion and alignment with other in-depth discussion Ensure additional interventions consider to health partners A and vitamin such as providing OPV, alongside type 1 for particularly feasible, where tablets, deworming should type 2 outbreaks for (Integration and 3 outbreaks. exceptionally.) be considered only Function Function Training Vaccine Vaccine management Immunization Information Information management Immunization Partner Partner coordination Partner Partner coordination Timeline until 14 days of completion immunization activities (75–90 days)

66 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Regional/Global Regional/Global Regional/Global UNICEF regional office and headquarters to and headquarters office UNICEF regional support provide OPRTT, WHO/UNICEF regional offices and offices WHO/UNICEF regional OPRTT, headquarters UNICEF regional office and headquarters and headquarters office UNICEF regional support provide to GPEI support from facilitate to OPRTT partners UNICEF regional office and headquarters and headquarters office UNICEF regional support provide to OPRTT to provide recommendations recommendations provide to OPRTT WHO regional office WHO regional GPEI support from facilitate to OPRTT partners OPRTT to provide support provide to OPRTT Responsibility Responsibility Country Country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from National health authorities, with support from and polio offices WHO and UNICEF country in country resources surge National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country Triangulation of data including: low performing areas, areas, performing including: low of data Triangulation or other observed children on refusals/missed social data etc. data surveillance social barriers, Conduct additional vaccinator and supervisor training and supervisor training Conduct additional vaccinator skills interpersonal for and regular supervision, monitoring Strengthen meetings during campaign review high-risk missed, reach to special strategies Initiate populations or mobile the quality of SIAs, improve Conduct activities to by GIS supported microplanning including detailed and feasible. appropriate mapping where Activities Activities Conduct trainings of front-line workers (vaccinators, (vaccinators, workers of front-line Conduct trainings skills, on technical and social mobilizers) supervisors SIA 1 and 2 skills for and interpersonal communication areas. targeted management and vaccine capacity cold-chain Assess SIA 1. fill gaps prior to to steps urgent and take capabilities subsequent immunization activities (SIA 1,Implement plan. response as per outbreak SIA 2, mop-up round) the quality of SIAs with each improve Conduct activities to subsequent round: • • • • • Extend support to immunization during the outbreak immunization during the outbreak support to Extend to capacity use of surge period, maximizing response management, microplanning, programme strengthen monitoring. mobilization and performance community the benefit of time- maximize effectively should The EOC actions in line selected RI, through support to limited Every of the Reaching components with the operational 7, and RED (See end of Chapter (RED)*approach. District guidance.) detailed for strategy Analyse and triangulate all data to assess population assess to all data and triangulate Analyse and progress sensitivity of surveillance immunity, transmission. interrupting towards Disposal of used, and partially used vaccine vials for vials for used vaccine Disposal of used, and partially Unopened vials should type 2 immunization response. control with access stores in strategic stored be securely (see closed is considered until the outbreak facilities management guidance). vaccine Ensure surveillance, SIA and monitoring data are are data SIA and monitoring surveillance, Ensure offices WHO and UNICEF regional and sent to completed timelines (within agreed to according and headquarters, AFP data). for all SIAs, and weekly for 14 days reports utilization and accountability vaccine Complete 0 (see vaccine including round each round, after management guidance). Review and adapt the outbreak response plan, including response and adapt the outbreak Review activities and communication immunization, surveillance made and/or progress subsequent phases. Track for gaps. any remaining close support needed to Liaise with in-country data managers to identify and to managers data Liaise with in-country issues. and completeness format data resolve Conduct regular donor meetings and advocacy activities. donor meetings and advocacy Conduct regular Ensure in-depth discussion and alignment with other in-depth discussion Ensure additional interventions consider to health partners A and vitamin such as providing OPV, alongside type 1 for particularly feasible, where tablets, deworming should type 2 outbreaks for (Integration and 3 outbreaks. exceptionally.) be considered only Function Function Function Routine Routine immunization: and recovery strengthening Data analysis Data Vaccine disposal Vaccine Information Information management Vaccine and reporting accountability Training Outbreak plan response Vaccine Vaccine management Immunization Information Information management Immunization Partner Partner coordination Partner Partner coordination Until close Until close of outbreak Timeline until 14 days of completion immunization activities (75–90 days) Timeline until 14 days of completion immunization activities (75–90 days)

RESPONDING TO A POLIOVIRUS 67 EVENT OR OUTBREAK Regional/Global Regional/Global OPRTT to coordinate to OPRTT WHE coordinate, to WHO headquarters with regional in consultation grade HQ to office Surveillance Task Team (STT) Team Task Surveillance coordinate to OPRTT Responsibility Country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country population immunity Notify and sensitize health care workers at national workers Notify and sensitize health care about notification units and subnational surveillance requirements in the AFP active sites reporting and reclassify Review network. surveillance at national workers Notify and sensitize health care about notification units and subnational surveillance requirements in the AFP active sites reporting and reclassify Review network surveillance increase to efforts and strengthen 1. Assess sensitivity surveillance and strengthen 2. Assess transmission. interrupting towards progress 3. Assess Activities A review of the grading is conducted every three months; three every is conducted of the grading A review will be adapted changes, the response if the grade accordingly. learned. lessons and share Document the response Continue surveillance enhancement activities (see enhancement Continue surveillance guidance): detailed 8 for chapter • • assessment response Conduct an independent outbreak in OBRA Aide- available guidance (OBRA) (detailed activities enhancement Continue surveillance Mémoire). guidance): detailed 8 for (See chapter • • reports utilization and accountability vaccine Complete 0 (see vaccine including round each round, after management guidance). Function Function Grading review - review Grading 3 months learnt Lessons Surveillance Surveillance enhancement OBRA - 3 months OBRA - 6, 9, 12 months etc. Timeline Until close of outbreak

68 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK

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70 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK